Airway Management in OR

1. Airway
Airway
management
management
Dr Saurav Das
Dr Saurav Das
When you cannot breath nothing else matter
When you cannot breath nothing else matter

2. • nose ANATOMY OF AIRWAY : The airway commences at the and extends
upto the terminal bronchioles.
•
• NOSE ; It can be divided into external and internal nasal cavity.
• EXTERNAL NOSE ; It has a bony part made of nasal bones nasal parts of
frontal bones and frontal process of maxilla.It has also a series of cartilage
in the lower part and a small zone of fibro-fatty tissue forming ala of the
nose.
• INTERNAL NOSE :The cavity of the nose is subdivided into two parts by the
septum which opens exteriorly into nares and posteriorly into nasopharynx
through choanae.
• Each side of the nose presents a roof,a floor a medial and a lateral wall.
• Roof :It slopes upward and backward to form the bridge of the nose (nasal
and frontal bones), has a horizontal part (ciribriform part of ethmoid) and
finally a downward slopping segment (the body of the ethmoid).
• FLOOR : It is concave from side to side is formed by the palatine process of
maxilla and the horizontal plate of palatine bone’
• The medial wall :It comprises of the septum formed by septal cartilage
.perpenicular plate of ethmoid and the vomer.
• The lateral wall ;It has a bony framework made up of nasal aspect of
ethmoidal labyrinth above, the nasal surface maxilla below and infront ,
and a perpendicular plate pf palatine bone behind it.It has three conchaes
each arching over a meatus.

4. • PHARYNX :It is a wide
fibromuscular tube which joins
the oral and nasal cavity in front
to the larynx below it. It extends
from the basilar part of the skull
to the origin of the oesophagus
at the level of C6 vertrebra .It is
divided into nasopharynx,
oropharynx and laryngopharynx

5. • Nasopharynx : It lies behind the nasal cavity
above soft palate.It communicates with the
oropharynx through pharyngeal isthmus
which is closed during deglutition by lifting
soft palate.The nasopharyngeal tonsil is
primary cause of obstruction in this region.
• Oropharynx :The mouth cavity leads to
oropharynx through the oropharyngeal
isthmus which is bound by the soft
palate,palatoglossus arches and the dorsum
of the tongue.

6. • Laryngopharynx It extends from from
the tip of the level of C6.Structurally
the larynx consists of framework of
articulating cartilages linked together
by ligaments which moves in relation
to each other by the action of
laryngeal muscles .
• Laryngeal cartilages :thyroid, cricoid ,
paired arytenoids with epiglottis
,corniculate and cuneiform cartilages.

8. • Trachea It extetends from the
lower border of cricoid cartilage
to its termination at the
bronchial bifurcation. It is about
15 cm long in adult and diameter
corresponds to that of patient
index finger’.

13. DEFINATIONS OF
DEFINATIONS OF
ABNORMAL AIRWAY
ABNORMAL AIRWAY
• DIFFICULT AIRWAY: In clinical
situation where a conventionally
trained anesthesiologist
experiences difficulty in mask
ventilation, difficulty with
tracheal intubation , or both.

14. DIFFICULT MASK
DIFFICULT MASK
VENTILATION ;
VENTILATION ;
• It is not possible for the unassisted
anesthesiologist to maintain the
SPO2 >90 % using 100% O2 and
positive pressure mask ventilation in
a patient whose SPO2 was >90%
before anesthetic intervention .
• It is not possible for the unassisted
anesthesiologist to prevent or
reverse signs of inadequate
ventilation during positive pressure
mask ventilation

15. • DIFFICULT LARYGOSCOPY :
• It is not possible to visualize any
portion of the vocal cords with
conventional laryngoscopy.
• DIFFICULT INTUBATION :
• Proper insertion of the tracheal
tube with conventional laryngoscope
requires more than three attempts of
or more than 10 mins.

16. FOLLOWING FACTORS CAN
FOLLOWING FACTORS CAN
COMPLICATE AIRWAY IN
COMPLICATE AIRWAY IN
OBSTETRICS PATIENTS
OBSTETRICS PATIENTS
• Increased body weight
• Large breast
• Increased mucosal edema and
vascularity
• Increased risk of aspiration
• Coexisting systemic disease
• Badly placed hip wedge
• Increased O2 consumption
• Decreased O2 store

17. • The essential components of
airway assessment:
• History taking
• General ,physical &regional
examination
• Physical indices
• Radiological evaluation

18. • HISTORY TAKING
• Review prior anesthetic records
• Ask the patient about the problems prior to anesthesia
such as jaw pain, hoarseness of voice ,dental injury
etc._that may suggest difficult intubation.
• If the patient was informed by the anesthtetist that he was
difficult to ventilate or intubate.
• The condition ,the pt had earlier might have worsened.
• History suggestive of following disorder: diabetes,
obstructive sleep apnoea , obesity. rheumatoid arthritis,
zenker
diverticulum,acromegaly,pregnancy,anaphylaxis,mediastin
al masses,xepiglottis,the airway in HIV patient,Ludwig,s
angina,retropharyngeal abscess.
•

19. • EXAMINATION;
• GENERAL, PHYSICAL AND REGIONAL
A global assessment should include
the following:
• Age , height, bodyweight, mouth
opening, teeth, palate, ability to
protrude the lower jaw, measurement
of sub mental space, patient neck
,general body habitus,infection of
airway, systemic diseases etc.

20. • Following patients are difficult to
Ventilate
• Obese
• Bearded
• Elderly
• Snorers
• Edentulous
• An image of snoring santa just about
sums it up..

21. •
• LEMON OR MELON PHYSICAL
SIGN
• look externally
• evaluate 3-3-2-1 rule
• mallampati score
• obstruction
• neck mobility

22. • Evaluate 3-3-2-1
• 3 finger between the patient’s
teeth
• 3 finger under chin
• 2 finger on the top of notch
• 1 finger lower jaw for
ant.subluxation

23. Mallampati score
Mallampati score
• Class1 -Visualization of soft
palate,fauces,uvula and both ant.
And post. Pillars.
• Class2- Visualization of the soft
palate ,fauces and uvula.
• Class-3 Visualization of soft
palate and the base uvula
• Class -4 visualization of hard
palate only

25. CORMACK AND LEHANE
CORMACK AND LEHANE
LARYNGOSCOPIC VIEW
LARYNGOSCOPIC VIEW
• Grade 1 visualization of entire
laryngeal aperture
• Grade 2 visualization of only
posterior commissure
• Grade 3 visualization of only
epiglottis
• Grade 4 visualization of just soft
palate

26. • LM –MAP RULE
• Look for external face
deformities
• Mallampati
• Measurements 3-3-2-1
• A –O extension
• Pathological obstructive
condition

27. • FOUR DS to suggest a difficult
airway
• Dentition
• Distortion
• Disportion
• Dysmotility

29. • Airway assessment-deduction derive
• whether the airway can be maintained with
mask
• whether mask ventilation is sufficient or
intubation would be needed
• If intubation is needed, can it be performed
safely with the patient anesthetized or an
awake intubation would be necessary
• Whether the patient can be safely paralyzed
or spontaneous respiration needs to be
maintained
• If nasal intubation is needed,if whether a
direct view is possible or must it be blind.

30. • MAGBOUL 4M & Ms
• Malampati
• Measurment
• Movement
• Malformation of skull,teeth,
obstruction, pathology

31. • PATIL TM DISTANCE TEST
• <6 cm = difficulty
• 6-6.5 cm =less difficult
• >6.5 = normal
• STERNOMENTAL DISTANCE
• Normal distance is 12.5 cm

32. • Cass and James’s 6 common anatomical
anomaly
• Short muscular neck with full set of teeth
• Receding jaw with an obtuse mandibular
angle
• Protruding upper incisor
• Poor mobility of the mandible
• Long and high arched palate
• Increased alveolar mental ridge distance
requiring wide opening of the mandible for
insertion of laryngoscope

33. • UPPER LIP BITE TEST
• Reflects subluxation of temporo
mandibular joint
• RHTMD
• The ratio of height to
temporomandibular distance
• The optimal cut off point for
RHTDM was 23.5

34. • RADIOLOGICAL EXAMINATION OF
THE AIRWAY
• To see whether there is
• Increased posterior depth of the
mandible
• Increased anterior depth of the
mandible
• Reduction in the distance between
occiput and spinous process c1

35. • Difficult airway cart-contents
– Face mask –all sizes
– Endotracheal tube
– Tongue depressor
– Stylets
– Laryngoscope
– Airways
– Magill,s forceps
– Suction apparatus
– Oxygen source
– A ventilating apparatus
– A head rest
– LMA
– Flexible fibreoptic laryngoscope
– Trcheostomy kit
– Equipment for retrograde intubation
– Combitube

38. • FASE MASK VENTILATION AND TECHNICQUE
• Anaesthesia face mask are rubber or plastic
employed to administer oxygen or to ventilate the
nonintibuted patient.
• The mask should be hold with index and thumb and
other three fingers to pull the mandible upward.
• Mandibular displacement along the cervical
extension and chin lift, all tend to pull the tongue and
soft tissue up of posterior pharyngeal wall and
relieve the obstruction of airway in anesthetized
patient.
• Some time, it may be required to hold the mask with
two hands and vigorously pulling the mandible
upward .

41. • AIRWAYS
• When airway integrity can be maintained with
manipulation of mask, mandible or neck a airway of
appropriate size can restore the patency .Air way are
two types – oral and nasal.
• Appropriate size of airway corresponds to distance
between angle of mouth to angle of mandible. The
airway may be inserted right side up or up side down
than rotated 180 degree into the position of function.
• Nasal airways are useful in patient who are not
deeply anesthetized because such airway tends to
provoke less airway stimulation.

44. • LARYNGOSCOPE
• The standard rigid laryngoscope
consist of a detachable blade with
removable bulb that connects to a
battery containing handle. Some
commonly used blades are
• Macintosh curved blade
• Straight millers blade
• Mc coy blade with a flexible tip

47. • Magill,s forcep
• Uses:
• To remove any foreign body
• To introduce rye,s tube
• To put pharyngeal pack
•

48. MAGILL,S FORCEPS
MAGILL,S FORCEPS

49. • ENDOTRCHEAL TUBE
• Most commonly used endotracheal
tubes are now a days transparent and
made of PVC.
• Cuffs with the tubes are high volume
low pressure cuff. cuff pressure
should be less than 20-25mmhg since
perfusion pressure of tracheal mucosa
is 25 to 35 mmhg

50. • E T TUBES

51. Technique of laryngoscopy
Technique of laryngoscopy
and intubation
and intubation
• In every case ,the anesthesiologist must attempt to
determine whether mask ventilation will be possible
if the patient anesthetized and paralysed.
• The usual sequence of intubations are
• For intravenous inducton a rapidly acting anesthetic
is first administered after preoxygenation for three
minutes.The drug can be one of them
• Thiopental,propofol,rapidly acting
barbiturates,ketamine
• A muscle relaxant is used to facilitate the
laryngoscopy.It can be depolarizing or non
depolarizing

54. • the head is maintained in classic sniffing position to
align the oral ,pharyngeal and laryngeal axes.
• Laryngoscope to be held with left while the fingers of
the right hand are used to open the mouth.
• The laryngoscope blade is inserted gently into the
right side of the patient mouth to avoid the incisor
teeth and to enable the flange of the blade to keep
the tongue to left.
• After visualization of epiglottis the curved blade is
placed into vallecula and with the full finger grip
hand the laryngoscope to pull forward and upward

55. • A gentle dorsal pressure on cricoid or BURP
maneuver of thyroid cartilage may improve
the glottic exposure.
• Endotracheal tube is inserted into the right
side of the mouth and placed between open
vocal cords under direct vision.
• In man, the tube is generally inserted about
23 cm at the lips and women it is 21cm
when tip of the tube is at 4cm above the
carina.
• Cuff if inflated with air so that there is no
audible leak.

56. • Following are the signs that tube
is in proper position
• Both side equal air entry on
auscultation
• Air column in tube
• And by capnography

57. RAPID SEQUENCE
RAPID SEQUENCE
INDUCTION
INDUCTION
• Steps are
• Preoxygenate at least for four
vital capacity breaths
• IV anesthetics and relaxants are
given together
• Apply cricoid pressure when
patient is unconscious.
• Ventilation prior to laryngoscope
is omitted here.

58. LARYNGEAL MASK
LARYNGEAL MASK
AIRWAY
AIRWAY
• Technique of insertion
• Sniffing the morning air head position
• Lubrication of the posterior part only
• The index finger of the operator’s hand may
be used to guide LMA over the back of
tongue
• The tip of the cuff is pressed posteriorly
against the hard palate
• The back longitudinal line on the shaft on
the LMA should face midline of the upper lip
• IIPV is accompanied by an audible leak

60. • THE COMITUBE
• It is double lumen tube that is inserted
blindly. The esophageal lumen has a closed
distal end. while inserting , the tongue and
mandible are lifted with one hand and
introduce the tube in the direction of normal
curvature of pharynx with the another hand
• Pharyngeal cuff is inflated with 100ml of air
and distal end with 15ml.Ventilation is
started with the longer tube because
placement is usually esophagus. If there is
no signs of lung ventilation and stomach
being inflated ,ventilation should be started
with second tube.

62. COMBITUBE
COMBITUBE

65. • NEEDLE CRICOTHYROTOMY
• In the event of inability to
intubate the trachea or ventilate
the lung needle cricothyrotomy
or tracheotomy are final steps.
•

66. • Advantages of cricothyrotomy
over tracheotomy are
• Can be performed in lateral
position
• Easier to perform
• Less instrumentation is needed
• Takes shorter time

67. • Procedure
• It is performed by by placing a 12-14 gauge
needle or catheter through cricothyrroid
membrane into the trchea. An alternative
site is the subcricoid region beween the
cricoid cartilage and the first tracheal
ring.The needle is fixed with an artery
forcep.Intermittent pressurized oxygen
provides the most suitable method for
ventilation through this small needle and
simplest method is to use emergency
oxygen flush.