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Chapter 50 - Airway Management in the Adult from Miller: Miller's Anesthesia on MD Consult

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Miller: Miller's Anesthesia, 7th ed.

Copyright 2009 Churchill Livingstone, An Imprint of Elsevier

50 Airway Management in the Adult

John Henderson

Key Points

Three basic decisions needed before induction of anesthesia in every patient are whether to use
awake intubation, use a percutaneous technique, or maintain spontaneous ventilation.


Conditions requiring particular caution include lesions at the base of the tongue, recent onset of
hoarseness, upper airway obstruction, and obstructive sleep apnea.


The combination of mouth opening, jaw protrusion, and head extension is the core of airway
assessment. The examination described by El-Ganzouri (mouth opening, prognathic ability, head
extension, thyromental distance, and the Mallampati test) has been used with minor modification by
others. It can be performed rapidly and is the most quantifiable (recording of actual values is
recommended) of the tests included in the guidelines of the American Society of Anesthesiologists


Radiology studies have shown that head extension is the most important single maneuver in
maintaining space between the pharyngeal soft tissues. Head extension stretches the anterior neck
structures and moves the hyoid bone and attached structures anteriorly.


Four principles are central to prevention of complications during tracheal intubation:

Maintenance of oxygenation must take priority over all other issues. Preoxygenation should
be performed before induction of anesthesia. Mask ventilation should be used between
attempts at tracheal intubation.

Trauma must be prevented. The first attempt at tracheal intubation should be performed
under optimal conditions, including patient position, preoxygenation, and equipment
preparation. The number of attempts with blind techniques should ideally be zero and
certainly not more than four.

Anesthesiologists should have a sequence of backup plans in place before starting the
primary technique. They should have the skills and the equipment needed to execute these
plans. When unanticipated difficulty occurs in non-lifesaving surgery, the safest plan is to
terminate attempts at tracheal intubation, awaken the patient, and postpone surgery.

Anesthesiologist should seek the best help available (call for help) as soon as difficulty
with tracheal intubation is experienced.


Immediate confirmation of correct tracheal tube placement is an essential and integral part of
tracheal intubation. Several tests should be used because no single test is completely reliable. The
most important safeguard is clinical suspicion. Visual confirmation of passage of the tracheal tube
between the vocal cords is reliable, but not always possible, and experienced anesthesiologists are
occasionally misled.


All anesthesiologists should be skilled in at least one alternative technique of tracheal intubation
under vision. Strategies that include algorithms for the management of unanticipated difficult
intubation have been devised by several organizations, including the ASA and the Difficult Airway
Society, a U.K. organization. The ASA algorithm is the standard guide.


If noninvasive techniques do not restore oxygenation, cricothyrotomy is the percutaneous airway of

choice because tracheotomy may take too long. It is not possible to define the SpO2 at which
cricothyrotomy should be performedit depends on the degree of hypoxemia and how rapidly it is


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Anesthesia was developed to enable the performance of therapeutic and diagnostic procedures that could
not be performed in conscious or sedated patients. The reduction in consciousness produced by general
anesthesia (or trauma or disease) is necessarily associated with depression of other physiologic systems.
The depressant effects on airway, respiratory, and cardiovascular function can cause immediate threats to
the patient. Airway management differs from management of other depressed function in that it requires a
range of manual skills, as well as knowledge and judgment.
Some components of anesthesia respiratory care have become safer in the last 3 decades. American Society
of Anesthesiologists (ASA) Closed Claims analyses show that nonspecific adverse respiratory system events
decreased from about 37% of respiratory claims in the 1970s to 14% of claims in the 1990s. However, the
proportions of claims attributable to difficult tracheal intubation has more than doubled. [1] The probable
explanation is that monitoring has reduced the number of adverse outcomes from nonspecific events but
prevention of adverse tracheal intubation outcomes is more difficult. Evidence of the limitations of traditional
techniques has accrued and effective new techniques have been developed. However, many
anesthesiologists continue to rely on multiple attempts with ineffective techniques.

The nose warms, filters, and humidifies incoming air and is the organ of smell. It consists of the external nose
and the internal nasal cavity. The nasal cavities are divided by the nasal septum, which is frequently deviated
with the consequence that the nasal cavities are narrowed or obstructed. The roof of the nasal cavity is the
cribriform plate, a thin bone that is easily fractured, thereby resulting in communication between the nasal
and intracranial cavities. The bony lateral wall of the nasal cavity is the origin of the three bony turbinates that
project into the nasal cavity. They are easily damaged by force during the passage of nasotracheal tubes.
Openings in the lateral wall communicate with the paranasal sinuses. Prolonged nasotracheal intubation
impairs drainage through these openings, causing sinusitis. The lining of the nasal cavity is very vascular,
and application of nasal vasoconstrictors to shrink the mucosa and dilate the airway reduces the risk of
hemorrhage during the insertion of airway devices or tracheal tubes.
The roof of the mouth is bounded by the alveolar arch and teeth and consists of the hard palate anteriorly and
the soft palate posteriorly. The tongue makes up most of the floor of the mouth, which is bounded by the
mandible and teeth. Nonencapsulated lymphoid tissue on the posterior surface of the tongue (lingual tonsil) is
part of the ring of Waldeyer. This tissue is important in that hypertrophy can cause serious difficulty in airway
management. [2] [3] The ability to achieve good mouth opening is important for many airway procedures. Initial
mouth opening is achieved by rotation within the temporomandibular joint (TMJ) and subsequent opening by
sliding (also known as protrusion, translocation, or subluxation) of the condyles of the mandible within the
TMJ. The jaw-thrust maneuver uses the sliding component of the TMJ to move the mandible and attached
structures anteriorly. The scissors maneuver ( Fig. 50-1 ) achieves maximum mouth opening by the
application of internal pressure on the teeth to achieve both TMJ movements. It can facilitate the insertion of
oropharyngeal airways, supraglottic airway devices (SADs), and laryngoscopes. All movements of the TMJ
should be firm but gentle to minimize the risk of joint damage.


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Figure 50-1 Scissors maneuver. The rotation and sliding components of the temporomandibular joint are used to achieve
maximal mouth opening.

The pharynx is a fibromuscular tube that extends from the base of the skull to the lower border of the cricoid
cartilage. It joins the nasal and oral cavities above with the larynx and esophagus below. Both the pharynx
and esophagus can be perforated by blind attempts at tracheal intubation. The nasopharynx is the part of the
pharynx that lies posterior to the nose. Nasotracheal tubes can impinge on the posterior wall of the
nasopharynx, and application of increasing force when resistance is met can cause submucosal passage of
the tube.
The larynx is situated at the upper end of the respiratory tract, where it extends from the epiglottis to the
lower end of the cricoid cartilage. It evolved as a valve to protect the lower respiratory tract from alimentary
contents and later developed into an organ of speech. The larynx bulges posteriorly into the laryngopharynx,
with the piriform fossa lying on each side. The larynx consists of a framework of articulating cartilage
connected by fascia, muscles, and ligaments. It is suspended from the hyoid bone by the thyrohyoid
membrane. The principal cartilages are the thyroid, cricoid, and posterior (arytenoid, corniculate, and
cuneiform) cartilage and the epiglottis. The cricoid cartilage is a complete ring that articulates with the thyroid


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and arytenoid cartilage. The arytenoid cartilage sits on the posterolateral border of the cricoid, from where it
can be dislocated [4] during airway management. The laryngeal inlet is bounded by the epiglottis, aryepiglottic
folds, posterior cartilage, and interarytenoid notch. The vocal cords run between the vocal processes of the
arytenoid cartilage and the posterior surface of the thyroid cartilage. The lower end of the leaf-shaped
epiglottis is attached to the middle of the posterior surface of the thyroid cartilage. The anterior surface is
connected to the hyoid bone by the hyoepiglottic ligament and to the tongue by the median glossoepiglottic
fold. The valleculae (often called vallecula) are depressions between the median and lateral glossoepiglottic
folds that connect the lateral edges of the epiglottis to the base of the tongue. The Macintosh technique of
laryngoscopy involves insertion of the tip of the laryngoscope into the vallecula, where it tensions the
hyoepiglottic ligament to achieve indirect elevation of the epiglottis.
During swallowing the larynx is protected by several mechanisms. The larynx is tucked up behind the tongue,
and the epiglottis diverts food away from the laryngeal inlet. The laryngeal muscles can be grouped according
to their actions on the vocal cords: abductors, adductors, and regulators of tension. Motor innervation to
these muscles and the sensory innervation of the larynx are supplied by two branches of the vagus nerve: the
superior and recurrent laryngeal nerves. The superior laryngeal nerve can be anesthetized at the point where
it passes through the thyrohyoid membrane. The recurrent laryngeal nerve can be damaged during surgery
on the thyroid gland or by pressure from a cuff that lies just below the vocal cords. [5]
The cricothyroid membrane joins the thyroid with the adjacent cricoid cartilage. It is close to the skin,
relatively avascular, and the widest gap between the cartilage of the larynx and trachea, so it provides the
best access for percutaneous airway rescue techniques. It is normally easy to palpate, but identification may
not be possible in obese patients. In patients with fixed neck flexion, the cricothyroid membrane may lie
behind the sternum.
The trachea extends from the lower edge of the cricoid cartilage to the carina. It consists of U-shaped
cartilage joined by fibroelastic tissue and is closed posteriorly by the longitudinal trachealis muscle. The
tracheal rings and trachealis muscle are responsible for the characteristic endoscopic appearance of the

Airway Assessment
Three basic decisions ( Fig. 50-2 ) needed before induction of anesthesia in every patient [6] are whether


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Figure 50-2 American Society of Anesthesiologists Difficult Airway Algorithm. (From American Society of Anesthesiologists
Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. An updated report
by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 98:1269-1277,

To use awake endotracheal intubation

To use a percutaneous technique

To maintain spontaneous ventilation

These three strategies are safer than the use of an intravenous anesthetic with neuromuscular blocking drugs
(NMBDs) in patients with potential airway difficulty, but they require more time and effort, and the
anesthesiologist needs evidence on which to base these decisions. The purpose of airway assessment is to
identify possible difficulty with direct laryngoscopy (and hence tracheal intubation), mask ventilation, or
creation of a surgical (percutaneous) airway. This traditional approach may change with the introduction of


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sugammadex, an antagonist to replace neostigmine, into routine clinical practice (see Chapter 29 ).
Rocuronium could be used to facilitate endotracheal intubation. If spontaneous ventilation is urgently needed,
sugammadex can reverse profound neuromuscular blockade (i.e., no response to peripheral nerve
stimulation) within 1.5 to 3.0 minutes.
Potential difficulty may be obvious in patients with anatomic or pathologic abnormalities, and further tests are
not needed. Conditions requiring particular caution include lesions at the base of the tongue, recent onset of
hoarseness, upper airway obstruction, and obstructive sleep apnea. However, the challenge is to detect
potential difficulty in apparently normal patients. Airway assessment includes taking a history and performing
a physical examination. Imaging is valuable in assessing a pathologic airway but is not practicable for routine
The history includes review of available previous anesthesia records, direct questioning of the patient, and in
those with reduced consciousness, a search for communication about previous airway difficulty. A history of
previous airway difficulty has a higher positive predictive value and lower negative predictive value than any
tests. [7] However, a history of previous easy laryngoscopy does not guarantee straightforward intubation
inasmuch as increased age or pathology may result in increased difficulty.
Airway tests to detect difficulty with direct laryngoscopy are based on anatomic features, and values have
been selected as probable indicators of difficulty. The combination of mouth opening, jaw protrusion, and
head extension is the core of airway assessment. [8] There is little interobserver variation in the assessment
of mouth opening and jaw protrusion. [9] Mouth opening is measured as the interincisor distance, and a value
of 4 cm (2 fingerbreadths) has been proposed as an indicator of probable difficult intubation. [10] The
prognathic ability of the mandible depends on the size and shape of the mandible in relation to the maxilla
and on TMJ function. Prognathic inability of the mandible (the mandibular incisors cannot be brought in line
with the maxillary incisors) is associated with difficult intubation. Limited head (more accurately described as
occipito-atlanto-axial) extension [10] impairs direct laryngoscopy. It can be measured as the angle between
the occlusal surface of the maxillary teeth and the horizontal, with angles of less than 20 degrees suggesting
difficult laryngoscopy. However, it is difficult to prevent extension of the midcervical vertebrae, so true head
extension is frequently overestimated. The Mallampati test (visibility of pharyngeal structures) is of limited
value on its own [11] but can be combined with an assessment of dentition. [12] The thyromental distance is of
limited value as a predictor of difficult laryngoscopy, [13] but examination ensures that the laryngeal cartilage
is palpated and submandibular compliance assessed. Evaluation of dentition is important in that caries or
periodontitis increases the risk for dental damage. Some dental patterns, such as protruding or single or
missing maxillary incisors, [14] increase the difficulty of direct laryngoscopy. The examination described by ElGanzouri and colleagues [7] (assessment of mouth opening, prognathic ability, head extension, thyromental
distance, and Mallampati test) has been used with minor modification by others. [3] It can be performed
rapidly and contains the most quantifiable (recording of actual values is recommended) of the tests included
in the ASA guidelines. [6]
Ventilation via mask requires the ability to achieve a seal between the mask and face and to overcome upper
airway obstruction. Limited mandibular protrusion, abnormal neck anatomy, sleep apnea, snoring, and
obesity are independent predictors of moderate or severe difficulty with mask ventilation. Snoring and a
thyromental distance of less than 6 cm are independent predictors of severe difficulty. [15] No test can
accurately predict complete failure of mask ventilation because its prevalence is as low as 0.07%. [7] Some
pathologic causes of difficult mask ventilation cannot be predicted. [2]
Creation of a surgical airway (necessary for the management of a cannot intubate, cannot ventilate
situation) depends on percutaneous access to the cricothyroid membrane. In some patients the cricothyroid
membrane cannot be identified or lies behind the sternum, and creation of a percutaneous airway will not be
possible. In such patients who have indications that laryngoscopy or mask ventilation will be difficult, the
safest strategy is to secure the airway while the patient is conscious.
Integration of the evidence of difficulty with direct laryngoscopy, mask ventilation, and creation of a surgical
airway has many limitations. The causes of difficult laryngoscopy are multifactorial, and single tests have
limited value [11] as predictors. Prediction is improved by combining the results of different tests. [8] Scores [7]
[8] are formulas that combine the results of tests. These scores have been developed to improve prediction of
difficulty but many omit at least one test of some value, and the indicators are not usually weighted for


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importance. It is more meaningful to describe the result of individual tests. Airway assessment cannot detect
some serious problems, including asymptomatic lesions [2] [3] in the vicinity of the larynx, skeletal factors, and
some varieties of TMJ dysfunction.
The problem with airway assessment is that the risk of difficulty is overestimated and not all cases of difficult
airway management can be predicted. However, serious airway morbidity, though infrequent, is a much
worse outcome than performing an awake intubation that might not have been necessary. Airway evaluation
gives some indication of potential difficulty and should always be performed. [6] The anesthesiologist must
then make a judgment of whether direct laryngoscopy, mask ventilation, and percutaneous rescue are likely
to be successful. The limitations of airway assessment mean that preparation of an airway strategy for the
management of unanticipated difficulty is the ultimate key to safe practice. Strategies are discussed later in
the section Challenging Airway Management Scenarios.

Physiology and Pathophysiology of the Upper Airway

Upper Airway Obstruction
In an awake patient, airway patency is maintained by muscle tone in the head and neck, particularly the
pharynx and tongue. As consciousness is lost and muscle tone is reduced, tissues fall backward under the
influence of gravity in a supine patient and can obstruct the upper airway. The order of importance of these
obstructing tissues is the soft palate (velopharynx), epiglottis, and tongue. Head extension (as a
consequence of tensioning the strap muscles) and jaw thrust move the hyoid bone and attached structures
anteriorly and relieve airway obstruction to a variable extent. Jaw thrust is also effective in reducing
obstruction at the velopharynx in slim but not in obese patients. The lateral position can be used alternatively
or in addition to the aforementioned techniques to allow the obstructing tissues to move downward so that
obstruction is reduced. [16]
There is now evidence of an additional dynamic component of upper airway obstruction when consciousness
is reduced. In the conscious state the tone of the pharyngeal muscles is increased by neural discharge just
before phrenic nerve discharge. Loss of pharyngeal tone and collapse of the narrow velopharynx play an
important role in upper airway obstruction during spontaneous ventilation in an anesthetized patient. [17] The
airway in the nose and nasopharynx is held open by bone and cartilage and in the larynx and trachea by
cartilage. Dynamic collapse of the intervening pharynx can occur when muscle tone is reduced. The structure
of a collapsible segment between two rigid tubes corresponds to the basic elements of a Starling resistor in
that flow can depend on the intraluminal pressure gradient or on transmural pressure in the collapsible area.
[17] Flow through the collapsible segment depends on how the intraluminal pressure upstream and
downstream relate to the tissue pressure around the pharynx. Factors that narrow the pharynx, increase
pressure around it, reduce pressure within it, or make its walls more compliant will increase upper airway
obstruction. The therapeutic consequence of dynamic collapse is that nasal continuous positive airway
pressure (CPAP) reduces dynamic upper airway obstruction. Nasopharyngeal airways might reduce this
dynamic airway obstruction.

Laryngospasm (reflex closure of the true vocal cords alone or with the false cords because of stimulation of
the intrinsic laryngeal muscles) can result from the combination of reflex hyperactivity at an intermediate
depth of anesthesia and noxious distant surgical or local stimuli. Laryngospasm is usually maintained well
beyond the duration of the stimulus. It is responsible for a significant proportion of postoperative critical
events. Morbidity and mortality may result from the immediate (hypoxemia and hypercapnia) and delayed
(negative-pressure pulmonary edema) consequences of laryngospasm, and thus every effort should be
made to rapidly relieve the airway obstruction caused by laryngospasm. [18] Management is discussed later.
Negative-pressure pulmonary edema [18] is a consequence of forceful inspiratory effort in the presence of a
closed glottis or other cause of upper airway obstruction. The subatmospheric alveolar pressure generated
promotes transudation of fluid from pulmonary capillaries into the interstitial space and alveoli. Small vessel
damage may be responsible for frank hemorrhage into alveoli. Management consists of relief of the
obstruction, oxygen therapy, and standard management of pulmonary edema. Most cases resolve rapidly,
but reintubation and positive-pressure ventilation are sometimes required.


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Oxygenation and Preoxygenation

Hypoxemia can occur in the time between induction of anesthesia and attainment of airway security and is
particularly likely if airway management proves difficult. It makes sense to maximize oxygen stores before
induction to prolong the period before the onset of hypoxemia in the event of serious difficulty with airway
management. The principal oxygen stores are in the lungs. These stores can be increased by using a
maneuver called preoxygenation (also know as denitrogenation), which is achieved by having the patient
breath 100% oxygen from a close-fitting facemask before induction of anesthesia. Several techniques of
preoxygenation have been described, and the most effective technique should be used. Deep breathing with
a high fresh gas flow for 1.5 minutes and tidal breathing for 3 minutes are equally effective. It is particularly
important to avoid leaks in the circuit, which are indicated by a flaccid reservoir bag and absence of a normal
capnograph waveform. Wherever possible, the end-tidal oxygen concentration should be used as a guide to
the adequacy of preoxygenation, with a value of 90% being well accepted. Preoxygenation in the semi-sitting
position prolongs the time to development of hypoxemia by increasing functional residual capacity in relation
to the supine position, particularly in an obese patient. [19] Use of positive end-expiratory pressure (PEEP)
during induction may further improve oxygenation. [20]

Pharmacology of Airway Management

The choice of pharmacologic technique is part of the essential planning of airway management and will be
influenced by both airway and surgical requirements, particularly for surgical access and neuromuscular
blockade. Satisfactory conditions for tracheal intubation are particularly demanding and may be facilitated by
several pharmacologic techniques, each of which has advantages and disadvantages. Direct laryngoscopy is
facilitated by a reduction in tone of the head and neck muscles. A high success rate and low risk for laryngeal
trauma are facilitated when the vocal cords are open and nonreactive, at the cost of reduced protection
against pulmonary aspiration.

Inhaled Induction of Anesthesia

Induction plus maintenance of anesthesia by the inhalation of gaseous and volatile anesthetics was the
original pharmacologic technique for anesthesia. It remains an important technique in situations such as lack
of venous access and anticipated airway difficulty in a patient who refuses awake techniques. A major
advantage of inhaled induction of anesthesia is that spontaneous ventilation is maintained while changes in
the depth of anesthesia and associated respiratory and cardiovascular effects occur gradually. Good
facemask technical skills are essential to prevent airway obstruction and leaks around the mask.
Deep anesthesia is necessary for direct laryngoscopy and tracheal intubation with inhaled anesthetics alone.
It can be complicated by hypotension, hypoventilation, and airway obstruction. A depth of anesthesia that
allows controlled ventilation has been recommended when sevoflurane is used. Prior administration of topical
anesthesia (e.g., 4% lidocaine, 3 to 5 mL) can facilitate tracheal intubation under lighter inhaled anesthesia.
Sevoflurane has advantages over other volatile anesthetics for inhaled induction of anesthesia. It has a low
blood-gas partition coefficient and causes minimal airway irritation, which facilitates rapid smooth attainment
of a depth of anesthesia sufficient for airway procedures. A rapid technique (single breath) in which the
patient breathes 8% sevoflurane from a prefilled anesthesia circuit has been advocated rarely but causes
apnea more frequently than the traditional technique does. Furthermore, seizure activity with sevoflurane is
more likely with rapid induction of anesthesia. [21]
Inhaled induction of anesthesia is very useful in a wide variety of difficult airway conditions. Its use has been
advocated in patients with stridor but can result in sudden airway obstruction, which prevents rapid reduction
of the depth of anesthesia. Relief of obstruction may be difficult or impossible, even when CPAP is used with
mask ventilation, so emergency cricothyrotomy may be required. Propofol infusion, with topical anesthesia
before endotracheal intubation, has been used successfully for the management of patients with a difficult
airway. [22] Caution is required because apnea can occur when propofol is infused in patients with normal

Intravenous Anesthesia with Neuromuscular Blocking Drugs


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The combination of an intravenous anesthetic with an NMDB is the pharmacologic technique most frequently
used for tracheal intubation in routine practice (see Chapter 29 ). It provides good conditions rapidly in most
patients inasmuch as neuromuscular blockade facilitates laryngoscopy, opens the vocal cords, and prevents
coughing. The high quality of intubating conditions produced by NMBDs reduces the risk for postintubation
laryngeal damage. [23] However, the apnea caused by this pharmacologic approach has disadvantages. If
tracheal intubation of an apneic patient proves impossible, oxygenation requires effective ventilation with a
facemask or SAD, neither of which is completely reliable. Pharmacologic techniques that produce apnea
should not be used when difficulty with tracheal intubation or mask ventilation is predicted. As indicated
previously, the use of sugammadex may alter the approaches to difficult intubation.
In routine practice, nondepolarizing NMBDs are often preferable to succinylcholine to prevent its side effects
(as described in Chapter 29 ). Succinylcholine is chosen when rapid onset and offset are important. Use of
rocuronium as an alternative to succinylcholine has been suggested to avoid the side effects unique to
succinylcholine. Although the duration of paralysis produced by rocuronium is very much longer, the use of
sugammadex as a reversal agent makes recovery from an NMBD as quick as that from succinylcholine and
more predictable. It is now clear that a combination of rocuronium and sugammadex can restore
spontaneous ventilation more rapidly than waiting for succinylcholine to wear off. Possibly the need for
succinylcholine may disappear completely.

Intravenous Anesthesia with Narcotics

The use of short-acting narcotics instead of NMBDs to facilitate tracheal intubation has been advocated as a
means of avoiding the side effects of succinylcholine. This technique is effective in many patients who have
no risk factors for difficult intubation. However, it has serious disadvantages. [24] Conditions for direct
laryngoscopy and tracheal intubation are worse than when NMBDs are used, so there is a higher frequency
of failed intubation and airway trauma. Arterial hypotension is more likely when large doses of intravenous
anesthetics and narcotics are given. [24] A higher incidence of laryngeal trauma when intubation is performed
without NMBDs has been reported. [23] Use of a large dose of narcotics when ventilation with a facemask or
SAD is intended has other significant disadvantages. It may produce apnea and delay the return of
spontaneous ventilation. More importantly, it can make ventilation of the lungs with a mask or SAD difficult or
impossible as a consequence of vocal cord closure, a problem sometimes attributed to chest wall
rigidity. [25] The combination of intravenous anesthesia with topical anesthesia of the larynx produces good
conditions [26] and may be a better alternative to the use of NMBDs.

Local Anesthetic and Awake Techniques of Airway Management

Tracheal intubation of a conscious patient can allow uninterrupted respiration and airway protection while
avoiding the risk to airway maintenance and protection inherent with general anesthesia. It is indicated when
there is a possibility of difficulty with airway management. Tracheal intubation of a conscious patient is often
called awake intubation. Good topical airway anesthesia, rapport, and gentleness are the keys to success.
Sedation is often used but cannot compensate for inadequate topical anesthesia and is dangerous in patients
with a critical airway. [27]
Topical anesthesia of the airway can be used to facilitate the performance of many airway procedures ( Box
50-1 ) in a conscious patient in whom reduced consciousness is likely to cause difficulty in airway
management. Direct laryngoscopy has long been used for awake intubation but is often difficult and can be
distressing for all involved. Use of a flexible fiberoptic laryngoscope (FFL) for tracheal intubation under topical
anesthesia was a milestone in safe airway management because intubation of a conscious patient could now
be achieved with minimal discomfort. This technique has become the standard for management of an
anticipated difficult airway. Options are preserved if awake flexible fiberoptic intubation is not successful:
surgery can be postponed and the patient awakened, an unhurried surgical airway can be performed, or
tracheal intubation can be attempted in a breathing patient (awake or inhaled induction) with other visual
Box 50-1


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Airway Techniques That Can Be Performed Under Topical Anesthesia in an Awake Patient

Supraglotti airway device insertion

Direct laryngoscopy and intubation
Blind nasal intubation
Retrograde intubation
Flexible fiberoptic laryngoscopy and intubation
Rigid indirect optical devices and intubation
Topical anesthesia reduces the caliber of a normal airway. Use of topical anesthesia in a patient with a
compromised airway can lead to loss of the airway and should be performed only by experts who have a
team prepared for immediate creation of a surgical airway.
Lidocaine has a better safety profile than other agents used for airway anesthesia. However, excessive doses
can cause fatal toxicity. Administration should be titrated and the mental state of the patient monitored. Blood
concentrations are influenced by the technique chosen, and aerosol delivery to the lower respiratory tract
should be minimized.
Several techniques of airway anesthesia are shown in Box 50-2 . Each has advantages and disadvantages.
Nebulizers have been used to deliver topical anesthesia to the airway. The optimum particle size is larger
than that required for the treatment of asthma. Simple aerosol techniques, such as injection into oxygen
flowing in a narrow tube, appear to work satisfactorily. Most of the inhaled solution is exhaled, and up to 20
minutes may be required to achieve satisfactory topical anesthesia. Inhalation of an aerosol of local
anesthetic is usually well tolerated and can anesthetize the entire respiratory tract. The quality of topical
anesthesia achieved with nebulizers is not as good as that achieved with other techniques, but it is a useful
option when other techniques cannot be used or coughing is particularly undesirable.
Box 50-2

Techniques of Airway Anesthesia

Nebulizersentire airway
Topical sprays and gelsupper airway
Transtracheal injectionlarynx and trachea
Spray as you golarynx and trachea
Nerve blocksdistribution of the nerve supply
Combinations of the above
Local anesthetic sprays and gels achieve rapid topical anesthesia of the nose, mouth, and pharynx.
Pressurized aerosol sprays contain preservatives that may cause a sore throat postoperatively, and they are
less effective than gels. Lidocaine 4% administered by a spray attachment for syringes is popular. The first
spray is pungent and patients should be warned. Lidocaine gel (2%) is very effective and well tolerated, but
subsequent optical images through the gel may be slightly impaired. Most of the lidocaine applied with sprays
or gels is swallowed and the absorbed drug metabolized in first-pass hepatic metabolism.
Topical anesthesia of the larynx and trachea may be achieved by transtracheal injection or a spray as you


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go (SAYGO) technique. SAYGO is an intermittent application technique that causes coughing and requires
time for recovery after each application. Use of an epidural catheter within the working channel of the
fiberscope is an effective means of administering SAYGO. Transtracheal injection through the cricothyroid
membrane is more invasive but quickly produces good topical anesthesia. Coughing spreads the local
anesthetic. A bolus of narcotic is frequently given before transtracheal injection to prevent excessive
coughing. Narcotics themselves can cause coughing, which can be suppressed by the inhalation of
salbutamol or beclomethasone or by intravenous lidocaine. [28] The quality of transtracheal anesthesia is
preferred by patients and endoscopists over that produced by nebulizers or SAYGO.
Nerve blocks produce more profound and longer-lasting anesthesia than topical anesthesia does. A superior
laryngeal nerve block created by injection through the thyrohyoid membrane is the least invasive of the
airway nerve blocks and provides good anesthesia of the area between the vocal cords and the epiglottis. [29]

Facemask Airway
Facemask techniques are a core skill that often requires considerable expertise. Use of a facemask with
spontaneous ventilation throughout induction and maintenance of anesthesia with inhaled agents is the
simplest and least invasive anesthesia technique. It is very suitable for short operations in all patients except
those with an increased risk of vomiting or regurgitation. Facemasks are also used for controlled ventilation
before and after the use of tracheal tubes.
Facemasks are designed to form a seal around the mouth and nose and to connect to a resuscitator or
anesthesia circuit. The two key elements of the technique are maintenance of a good seal between the mask
and the patient's face and an unobstructed airway. Clinical signs of air leak and airway obstruction must be
sought constantly. The quality of the seal during spontaneous ventilation is monitored by observing the
fullness and movement of the reservoir bag. Leaks occur most frequently around the nose and cheeks, the
latter particularly in edentulous patients with concave cheeks. It is possible to compensate for a leak by using
a high fresh gas flow, but use of the oxygen flush facility on the anesthesia machine will dilute the
concentration of any inhaled agents being administered.
The pathophysiology of upper airway obstruction has been considered. The clinical features of airway
obstruction depend on the site and degree of obstruction and whether spontaneous breathing or positivepressure ventilation is being used. Laryngospasm may be a component of airway obstruction and is
considered separately. The most important signs of airway obstruction are clinical. Noisy respiration
(snoring with supraglottic obstruction and inspiratory stridor with glottic obstruction) is a classic sign of
airway obstruction during spontaneous ventilation. However, noise depends on airflow, which is determined
by the degree of obstruction and the respiratory drive. Powerful inspiration in the presence of airway
obstruction produces the combination of inward movement of the upper chest region and outward movement
of the lower chest and upper abdominal regions, thereby creating the classic seesaw movement sign.
Powerful descent of the diaphragm in the presence of severe obstruction results in tracheal tug. Movement of
the reservoir bag is a guide to tidal volume, which can be supplemented by electronic measurement.
Reliance on the capnograph alone is dangerous. Serious hypercapnia caused by airway obstruction can exist
despite a satisfactory SpO2.
Radiology studies have shown that head extension is the most important single maneuver for maintaining
space between the pharyngeal soft tissues. Head extension stretches the anterior neck structures and moves
the hyoid bone and attached structures anteriorly. In patients with an unstable cervical spine, head extension
should be used only if all other airway maneuvers fail to overcome the airway obstruction. Jaw thrust,
achieved by exerting anterior pressure behind the angles of the mandible, uses the sliding component of the
TMJ to move the mandible, hyoid bone, and attached structures anteriorly. Considerable strength is
sometimes required to overcome airway obstruction with head extension and jaw thrust. Use of the lateral
position can dramatically reduce airway obstruction. [16]
If head extension and jaw thrust fail to maintain an unobstructed airway, options include insertion of an
oropharyngeal airway, nasopharyngeal airway, or SAD and tracheal intubation. An oropharyngeal airway
( Fig. 50-3 ) is normally the first choice, provided that sufficient mouth opening is possible. The airway should
be inserted only when the pharyngeal and laryngeal reflexes are depressed to minimize the risk of provoking
coughing and laryngospasm. The risk of damage to the teeth during the insertion of oropharyngeal airways is


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increased in the presence of caries and gingivitis.

Figure 50-3 Oropharyngeal airway in place. The airway follows the curvature of the tongue. It pulls the tongue and the epiglottis
away from the posterior pharyngeal wall and provides a channel for the passage of air. (Adapted from Dorsch JA, Dorsch SE:
Understanding Anesthesia Equipment, 4th ed. Baltimore, Williams & Wilkins, 1999.)

If airway obstruction is not improved with the oropharyngeal airway, the next step has traditionally been
insertion of a nasopharyngeal airway ( Fig. 50-4 ), which often dramatically improves the airway.
Nasopharyngeal airways may be preferable to oropharyngeal airways in the presence of limited mouth
opening and dental caries or gingivitis. Once in place, a nasopharyngeal airway is less stimulating than an
oral airway and better tolerated by lightly anesthetized patients. Insertion of a nasopharyngeal airway can
cause epistaxis as a consequence of damage to the nasal mucosa, polyps, turbinates, or other tissues. This
risk is minimized by gentle insertion of a well-lubricated small airway and termination if resistance is met.
Unless other measures fail to maintain an adequate airway, nasopharyngeal airways should not be used in
patients with basal skull fracture because of the risk of intracranial insertion. Ventilation through an SAD may
be successful when facemask ventilation fails. A laryngeal mask airway (LMA) is now frequently inserted


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before trial of a nasopharyngeal airway if mouth opening is adequate and the depth of anesthesia is
sufficient. Successful tracheal intubation will improve the airway when facemask ventilation is inadequate but
may be hazardous because difficulty with facemask ventilation is associated with difficult tracheal intubation.

Figure 50-4 The nasopharyngeal airway in place. The airway passes through the nose and ends at a point just above the
epiglottis. (Adapted from Dorsch JA, Dorsch SE: Understanding Anesthesia Equipment, 4th ed. Baltimore, Williams & Wilkins,

When airway obstruction makes facemask positive-pressure ventilation difficult, any of the aforementioned
maneuvers may be used. Use of increased airway pressure has a good theoretical basis as a means of
overcoming dynamic airway obstruction. Two-person techniques are of proven value. The more experienced
person maintains head extension, bimanual jaw thrust, and mask seal while an assistant squeezes the
reservoir bag under supervision. Excessive airway pressure should be avoided because it may insufflate gas
into the stomach, thereby increasing the risk for regurgitation. Mask ventilation may be difficult or impossible,
[2] particularly when cricoid pressure is applied.


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Laryngospasm during Anesthesia

The pathophysiology of laryngospasm has been discussed. Laryngospasm during surgery can occur during
use of a facemask or SAD. The clinical picture depends on the degree of obstruction and the respiratory
drive. High-pitched inspiratory stridor is a classic sign, but complete airway obstruction is silent. Obstruction
must be relieved rapidly to prevent hypoxemic damage and the development of negative-pressure pulmonary
edema. [18] Mild laryngospasm should be managed initially with positive-pressure ventilation by facemask
along with head extension and jaw thrust. The Larson maneuver of inward pressure in the laryngospasm
notch (between the mandible and mastoid process) has no disadvantages and should be attempted. [30]
When laryngospasm is severe with complete glottic closure, attempted facemask positive-pressure ventilation
is ineffective because it distends the piriform fossae and presses the aryepiglottic folds more firmly against
each other. The depth of anesthesia may be increased rapidly with intravenous anesthetics (preferably
propofol). Stimulating surgery should be interrupted. If the obstruction or hypoxemia does not improve, a
small dose (e.g., 0.1 mg/kg) of succinylcholine can relax the vocal cords for about 2 minutes and give time to
increase the depth of anesthesia. This dose usually causes brief apnea, and laryngospasm may recur when
neuromuscular transmission recovers. If the obstruction or hypoxemia is severe, an intubating dose of
succinylcholine followed by tracheal intubation is indicated. If tracheal intubation fails, a percutaneous airway
will be necessary.

Supraglottic Airway Devices

SADs have been used widely since the 1990s. They provide an airway intermediate between the facemask
and tracheal tube in terms of anatomic position, invasiveness, and security. All are designed to form a seal in
the pharynx between the respiratory and digestive tracts to protect the airway and facilitate gas exchange. All
have a proximal tube that is connected to an anesthesia circuit or other device. All SADs are inserted blindly,
and tests are then used to determine whether their function is satisfactory. Many classifications have been
proposed; a simple differentiation is between esophageal obturator and periglottic devices.

Esophageal Obturator Devices

A tube with a closed distal end that is designed for passage into the esophagus is common to all esophageal
obturator devices. A distal seal in the esophagus is provided by an inflatable cuff, and a proximal seal is
achieved with a facemask or oropharyngeal cuff. Holes in the tube between the proximal seal and the distal
cuff deliver gases to the laryngopharynx. The Combitube has been widely used in prehospital care. The
proximal seal is provided by an oropharyngeal cuff. It has a second open-ended tube that can function as a
tracheal tube if it is inadvertently inserted into the trachea. It gives protection against regurgitation similar to
that provided by modern periglottic devices. The incidence of esophageal damage should be reduced when
the SA (small adult) size is used. Its performance is inferior to that of the ProSeal LMA (PLMA) and the
Laryngeal Tube Sonda (LT), [31] but it has been successful when other devices have failed. The LT is a
single-lumen esophageal obturator device in which both cuffs are inflated from a single inflation line. Multipleand single-use versions are available, and the size and number of holes between the two cuffs have been
increased. Placement is rapid and the incidence of laryngospasm and coughing is low. The LT achieves a
high leak pressure, thus facilitating higher airway pressure than with the LMA classic (LMAc) during positivepressure ventilation. The LT has been used successfully in the cannot intubate, cannot ventilate situation
and LMA failure. A gastric drainage tube was added in the Sonda models and perform well. [31] Other
esophageal obturator devices are also available.

Periglottic Devices
Periglottic devices form a seal around the larynx, usually with an inflatable cuff. Most clinical experience has
been with the LMA family of devices, and only these will be described in detail here. This does not imply that
other devices are not of value.
The original LMA (now also known as the LMAc) was introduced into clinical practice in 1988 and has been
used in more than 200 million patients. All LMAs have three main components: mask, airway tube, and
inflation line. The mask has a bowl surrounded by an inflatable cuff, which is designed to form an airtight and
fluid-tight seal round the larynx. The airway tube has a standard 15-mm connector.


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Large LMAs may increase the risk for sore throat postoperatively but achieve a better seal. [32] An LMA is
inserted blindly and thus gentleness is important. [33] Several insertion techniques will achieve an acceptable
position and function in most patients. The technique developed over many years by Archie Brain (the
inventor) ( Fig. 50-5 ) is reliable but not always successful, and alternative techniques are sometimes needed.
The sniff position is recommended for insertion of an LMA.

Figure 50-5 Insertion of a laryngeal mask airway (LMA). A, The tip of the cuff is pressed upward against the hard palate by the
index finger while the middle finger opens the mouth. B, The LMA is pressed backward in a smooth movement. Notice that the
nondominant hand is used to extend the head. C, The LMA is advanced until definite resistance is felt. D, Before the index finger
is removed, the nondominant hand presses down on the LMA to prevent dislodgment during removal of the index finger. The cuff
is subsequently inflated, and outward movement of the tube is often observed during this inflation. (Courtesy of LMA North
America, Inc., San Diego, CA.)

Propofol or sevoflurane give good conditions for insertion of an LMA. The combination provides particularly
good conditions with a low incidence of apnea and movement during insertion. [34] Short-acting narcotics
improve the ease of insertion and airway patency. [35] Alfentanil (10 g/kg) suppresses swallowing, coughing,
gagging, and laryngospasm without unduly long apnea. Intravenous lidocaine facilitates LMA insertion and
reduces the incidence of coughing and airway obstruction. Insertion should be performed only after an
adequate depth of anesthesia has been achieved, best demonstrated by the ability to perform a jaw thrust.
The recommended technique involves passing the device along the palate and then the posterior pharyngeal
wall until resistance increases, at which point the tip should be lie within the upper esophageal sphincter. This
route should reduce the risk of posterior displacement of the epiglottis. Malposition of the LMA is less likely if


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jaw thrust or direct laryngoscopy is used to assist insertion. The laryngoscope-assisted technique has been
successful when the standard technique has failed.
When resistance to insertion is detected, the tube is left free while air is inflated into the cuff. Inflation to the
maximum recommended volume produces high cuff pressure and suboptimal function. Inflation to a cuff
pressure not higher than 60 cm H2O is recommended. The tube is connected to the anesthesia circuit and
gentle manual ventilation begun. Initial checks of LMA function are now performed. Lung expansion is
observed. Slow refill of the reservoir bag is a feature of airway obstruction. Auscultation over the neck may
detect sounds of respiratory obstruction. When airway obstruction is detected, examination with an FFL is
recommended because management of LMA impaction in the glottis is different from that of vocal cord
LMA function is now assessed in more detail ( Box 50-3 ). Two tests that correlate well with optimum position
are the ability to generate an airway pressure of 20 cm H2O and the ability to ventilate manually. [36] Gas
exchange and the possibility of obstruction are assessed by capnography, expired tidal volume, and the flowvolume loop. Airway leak pressure may be used to quantify the efficacy of the seal between the mask and
the larynx and indicates both the feasibility of positive-pressure ventilation and the degree of airway
protection. The test is performed by determining the airway pressure at which gas escapes.
Box 50-3

Assessment of Function of the Laryngeal Mask Airway

Observation of airway pressure and chest movement with a manual ventilation

Reservoir bag refill during expiration
Auscultation over the neck
Cuff leak pressure
Expired tidal volume and flow-volume loop
Examination with a flexible fiberoptic laryngoscope
An effective seal depends on the size and position of the LMA, inflation of the cuff, low airway resistance, and
high pulmonary compliance. Poor initial function may be caused by laryngospasm or bronchospasm.
Withdrawal followed by readvancement (the up-down maneuver) may improve position and function of the
LMA. The number of maneuvers should be limited because airway obstruction is occasionally caused by
undiagnosed laryngeal lesions or laryngeal closure. If the airway remains unsatisfactory, the anesthesiologist
may reinsert the same or a different size of LMA and accept some leakage, or use a facemask or tracheal
The laryngeal mask is secured. A bite block should be inserted and remain in place until the LMA has been
removed to reduce the possibility that biting will obstruct the airway or damage the tube.
Airway Obstruction

The final position of the LMA in relation to the vocal cords, epiglottis, and upper part of the esophagus varies
greatly and has been investigated with the FFL. The average views obtained in 26 studies included an
unobstructed view of the vocal cords in 40% and no view of the vocal cords in 6%. [37] Malposition occurs in
50% to 80% of patients, is usually associated with an undefined clinically acceptable airway, [37] but can
adversely affect the quality of the airway.
There have been few scientific investigations of airway resistance as a measure of obstruction during the
clinical use of SADs. An important study showed that although median airway resistance was similar in the
LMA (plus larynx) and tracheal tube groups, airway resistance was greatly increased in 3 of 12 patients in the


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LMA group, indicative of significant airway obstruction. [38] Conversion to tracheal intubation has been
required in 11.4% of patients in whom the LMA was used for tonsillectomy. [39] Head extension and jaw thrust
have been required in 5% of patients. Failure to achieve a satisfactory airway occurred in 4.7% of LMA
patients in one large study. [10] Variation in the incidence of acceptable or obstructed airways may be partly
a consequence of differences in clinical criteria. Airway obstruction unresponsive to simple measures should
be no more acceptable than with a facemask and should be relieved. Reversion to a facemask is often
effective. Emergency intraoperative tracheal intubation is sometimes necessary and is likely to be more
hazardous than elective intubation ( Box 50-4 ).
Box 50-4

Hazards of Intraoperative Tracheal Intubation

SurgeryAdverse Effects
Sterility, integrity, and outcome threatened
Tracheal Intubation Problems
Patient position suboptimal
Hypoxemia and risk of increased hypoxemia
Risk of tissue trauma
Pulmonary Aspiration

The seal achieved by LMAs provides less protection against pulmonary aspiration than a properly inserted
cuffed tracheal tube does. LMA malposition in which the upper end of the esophagus lies within the bowl of
the LMA increases the risk that regurgitation or vomiting will result in pulmonary aspiration and has been
reported in a third (or more) of patients. Massive pulmonary aspiration during LMA anesthesia is infrequent
but can lead to death or serious morbidity. [40] The LMA should not be used in patients with an increased risk
for regurgitation or vomiting.
Positive-pressure ventilation, with or without NMBDs, is frequently used with the LMA. Despite reports of safe
use in large series, there is concern about the safety of this practice. [41] Positive-pressure ventilation
increases the risk for gastric insufflation, which in turn increases the risk for regurgitation.
Removal of the Laryngeal Mask Airway

Laryngeal function is depressed after LMA use. [42] Monitoring and oxygen administration should be
continued during emergence from anesthesia. Removal of the LMA should always be carried out at locations
where personnel and equipment are available to perform tracheal intubation. Most keep the LMA in place
until consciousness recovers, airway reflexes return, and patients can open their mouth on command.
Removal with the cuff inflated is associated with a higher incidence of hoarseness but not overall airway
complications, and many recommend this technique.
Comparison of the Laryngeal Mask Airway with the Facemask and Tracheal Tube

Basic skill is mastered more readily with an LMA than with a facemask. A reasonable success rate is
achieved more rapidly with an LMA than with the Macintosh technique of tracheal intubation. A greater
degree of skill is required for tracheal intubation. An LMA is inserted blindly, whereas a tracheal tube is
normally inserted under vision. Difficulty in LMA insertion occurs in at least 4.5% of patients, a incidence
comparable to that of difficulty with the Macintosh technique. LMA insertion causes less hemodynamic
stimulation than laryngoscopy and tracheal intubation do. The LMA has advantages over tracheal intubation
at the time of extubation. The incidence of minor laryngopharyngeal morbidity is similar with both devices.
However, coughing is less frequent at LMA than at tracheal tube removal, and adverse hemodynamic effects


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occur less frequently. The glottic aperture is narrowed after tracheal intubation but not with use of an LMA. [42]
Complications and Contraindications

There are few published reports of serious complications as a consequence of LMA use, but there have been
unreported deaths and cases of brain damage. [43] Less serious complications include nerve damage.
Role of the Laryngeal Mask Airway

The LMA is extremely useful when used conservatively and has proved valuable as a rescue device. The
LMA is a key device at several places in the ASA algorithm for difficult airways. [6] There are many reports of
successful use of an LMA as a rescue airway when tracheal intubation had failed, including the cannot
intubate, cannot ventilate situation, and lives have been saved. However, the LMA does not always provide
a satisfactory airway in the failed tracheal intubation situation. [2] Cricoid pressure can interfere with the
insertion and function of SADs and should be reduced to a level that allows successful insertion and
adequate function. An LMA may be used to allow completion of surgery if the latter cannot be postponed,
although there is a risk of airway obstruction and pulmonary aspiration. The most prudent course is to
postpone surgery and awaken the patient or to convert to tracheal intubation with a visual technique such as
the Aintree intubating catheter (AIT).
Elective use of an LMA in a patient with a known or anticipated difficult airway has serious disadvantages.
The difficult airway remains and the development of airway obstruction could produce a critical situation that
requires immediate percutaneous airway rescue. Asai states, It is inadvisable to rely on the LMA when
tracheal intubation is predicted to be difficult. [43a] Although the LMA has been inserted under topical
anesthesia, gagging, coughing and a high incidence of sore throat have been reported. [44] The LMA has
failed to provide a satisfactory airway in patients with micrognathia, previous oral or cervical radiotherapy,
and laryngeal abnormalities and disease. Insertion of an LMA is frequently difficult in patients in whom
tracheal intubation is difficult. Use of an LMA when the patient's position is other than sniff will delay
conversion to tracheal intubation when necessary. The development of airway obstruction with such positions
places the patient at risk, requires rapid repositioning of the patient by staff, and jeopardizes the surgical
outcome. The risks associated with intraoperative tracheal intubation (see Box 50-4 ) will be increased.
The LMA has been used safely for major surgery, but the user must be very experienced with both the LMA
and tracheal intubation, and that is the paradox. If future generations of anesthesiologists were to have less
skill in tracheal intubation, use of an LMA instead of tracheal intubation for major surgery would become more
risky. Skill in tracheal intubation is essential, and it is generally the safer option. Insertion of an LMA is
regarded as less stressful for the anesthesiologist than the use of direct laryngoscopy for tracheal intubation.
However, a tracheal tube is a more reliable airway that provides better protection against pulmonary
aspiration. Most comparisons with tracheal intubation have used the Macintosh laryngoscope, the limitations
of which are now better understood. [45] It is probable that problems and complications with tracheal
intubation will become less frequent as alternative intubation techniques are used more regularly. [46] [47]
Expediency and some minor advantages of SADs must be offset against lower airway security and reliability.
Patient safety must always be the prime concern.

Newer Supraglottic Airway Devices

Flexible, intubating, and ProSeal LMAs have been introduced. Several changes have been made to improve
the performance of newer models. The LMA Flexible has a wire-reinforced, flexible airway tube designed to
resist kinking during oral or other head and neck surgery. Some SADs introduced by other manufacturers
perform well. The i-gel and LMA Supreme seem very promising, but there are still limited data and other new
devices will certainly appear.
ProSeal Laryngeal Mask Airway

The PLMA was designed to facilitate positive-pressure ventilation with higher airway pressure than possible
with the LMAc. A second posterior cuff and deeper bowl were designed to improve the seal around the
larynx. The PLMA has a drainage tube to provide access to the esophagus. Other features of the PLMA
include a reinforced airway tube that is narrower than that of the LMAc and an integrated bite block. The tip of


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the PLMA lacks the semirigid back plate of the LMAc.

Insertion Technique

A greater depth of inhaled and intravenous anesthesia is required for insertion of a PLMA than an LMAc. The
technique of PLMA insertion is more demanding than that for an LMAc, but a high success rate can be
achieved. [48] This effort is rewarded by a superior quality of airway. Airway seal pressure is increased by
50% in relation to the LMAc, thus facilitating positive-pressure ventilation and probably providing better
airway protection. The device may be introduced digitally or with a special introducer. An alternative
laryngoscope introducer technique has been developed to prevent folding of the mask tip during insertion. A
lubricated introducer is passed through the PLMA drainage tube so that it protrudes beyond the tip. A
Macintosh laryngoscope is used to facilitate insertion of the introducer into the esophagus. The laryngoscope
is then removed and the PLMA inserted by using the introducer as a guide. This technique may be the most
reliable but is most invasive method of PLMA insertion. After insertion, the PLMA cuff is inflated to a pressure
not greater than 60 cm H2O.
An incorrectly placed PLMA will result in unreliable or obstructed ventilation. The diagnosis of correct and
incorrect PLMA position is considered in detail because it may be relevant to a new generation of SADs that
incorporate a drainage tube. Correct placement of the PLMA should produce a leak-free seal around the
glottis with the mask tip and drainage tube lying inside the upper esophageal sphincter. There are three
important malpositions of the PLMA: (1) The PLMA may not be inserted sufficiently far, with the consequence
that the tip of the drainage tube lies in the pharynx. Positive-pressure ventilation is ineffective because
delivered gas passes out the drainage tube. (2) The tip of the PLMA may lie within the glottis, thereby
obstructing ventilation and impairing function of the drainage tube. (3) The tip may be folded over and
obstruct ventilation and the drainage tube. Malposition should be corrected by repositioning the PLMA, using
a different insertion technique, or replacing it with an alternative airway device.
Initial checks of function are identical to those used with the LMAc. In particular, chest expansion should be
good with reasonable airway pressure, and there should be no signs of obstruction of expiration, particularly
slow refill of the reservoir bag. The capnograph should be square and the flow-volume loop closed without
expiratory scalloping or other signs of obstruction. Airway leak pressure should be greater than 20 cm H2O.
Additional checks unique to devices with a drainage tube may then be performed. A thin layer of watersoluble gel or nontoxic soapy film is used to cover the proximal end of the drainage tube. The effect of
changes in pressure in the lungs (sternal compression or positive-pressure ventilation) or esophagus
(pressure on the suprasternal notch) are noted. Normal results are as follows:

The drainage tube gel does not move with positive-pressure ventilation or brief firm pressure applied
to the sternum.

The drainage tube gel does not move when airway pressure is raised to 20 cm H2O.

The drainage tube gel moves slightly when brief bobbing pressure is applied to the suprasternal
notch (the mechanism is pressure on the esophagus).

Protection against Pulmonary Aspiration

The PLMA provides greater protection against pulmonary aspiration than the LMAc does. In clinical practice,
the PLMA has prevented aspiration in the presence of massive regurgitation. However, pulmonary aspiration
has occurred when malposition of the PLMA was not corrected and function checks had been satisfactory.
The PLMA provides good but incomplete protection against pulmonary aspiration.
Airway Obstruction

Significant airway obstruction has been reported with the PLMA. Intraoperative tracheal intubation was
required in 13% of obese patients undergoing laparoscopic cholecystectomy. [49] Obstruction may be caused
by malposition or obstruction of the bowl by folds of the inflated cuff, by narrowing of the glottis via direct
pressure, or by laryngospasm during use of a properly positioned PLMA.
Use of the PLMA during major surgery such as laparoscopic cholecystectomy has been advocated [49] but is
controversial. [41] Use of the PLMA for such surgery should be considered only in patients who have no extra


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risk factors (including obesity, symptomatic gastroesophageal reflux disease, reduced compliance, increased
airway resistance) for SAD use. The anesthesiologist must be ready to convert to tracheal intubation at any
time. [49] Tracheal intubation provides a more secure airway and should be the norm for major surgery.

Single-Use Supraglottic Airway Devices

The original LMAs were designed for use up to 40 times. Protein contamination occurs after the first use and
increases with each subsequent use despite proper cleaning and autoclaving. Single-use SADs have been
developed to prevent cross-infection. Ease and quality-of-use results from different studies have been

Tracheal Tubes
Tracheal tubes are designed to provide a secure channel through the upper airway. The distal end lies in the
mid to lower part of the trachea, whereas the proximal end lies outside the mouth or nose, where it is
connected to an anesthesia circuit or other device. Tracheal tubes used in adult patients have a cuff near the
distal end that is inflated to provide a seal against the tracheal wall to protect the lungs from pulmonary
aspiration and to ensure that the tidal volume delivered ventilates the lungs rather than escapes into the
upper airway. Cuffs are normally inflated with air and have an inflation tube with a pilot balloon that indicates
cuff inflation.
The size of the tracheal tube is normally described as the internal diameter (ID) in millimeters, but the
relationship of the ID to the external diameter varies between different designs and manufacturers. Use of the
largest possible tracheal tube was once considered good practice. Very small tracheal tubes may allow
insufficient time for completion of exhalation and produce air trapping (auto-PEEP) with the risk of
barotrauma and circulatory compromise. Others have found no evidence of obstruction to expiration with tube
sizes as small as 6-mm ID, and the increased workload created is usually of little clinical significance during
anesthesia. Use of small tracheal tubes reduces the incidence of sore throat and hoarseness. Small tracheal
tubes are easier to insert than larger tubes and may cause less tissue pressure at the larynx. It is easier to
pass small tracheal tubes over introducers or FFLs. [50] Restriction of gas flow through a tracheal tube is
markedly increased by the presence of an FFL or suction catheter within the lumen of the tracheal tube.
Tracheal tube sizes of 8 mm (ID) for males and 7.5 mm (ID) for females are often used.
Specialized tracheal tubes produced for anesthesia include preformed, adjustable shape, and reinforced.
Specialized tubes are also used for ear, nose, and throat (ENT) surgery (laser and microlaryngeal surgery)
and for thoracic anesthesia and critical care. Tracheal tubes can become kinked and hence obstructed when
they are angulated. Armored (reinforced) tubes have an embedded coil (usually stainless steel) that
minimizes kinking of the tube when it is subjected to angulation. Armored tracheal tubes are the tubes of
choice in many head and neck procedures and patient positions other than supine. However, an armored
tube that has been compressed remains pinched, so it is particularly important to prevent biting on such a
The material and bevel shape of the tip of the tracheal tube can affect the ease and probably the trauma of
tube passage. The tip of the earliest Magill tracheal tubes had a soft, simple bevel. The Murphy eye, a hole in
the wall of a firm tip opposite the bevel, was designed to provide a patent airway if the tracheal tube became
occluded at the bevel. Air leakage through the Murphy eye may facilitate early diagnosis of tracheal tube
displacement before complete accidental extubation has occurred.
Cuff inflation achieves a seal between the tracheal tube and the wall of the trachea. There should be no air
leak at airway pressures required for positive-pressure ventilation, and the lungs should be protected from
aspiration. The cuffs of early tracheal tubes produced a high pressure that could cause mucosal ischemia.
High-volume, low-pressure cuffs were developed to conform to the D-shaped cross section of the trachea
and provide a seal at a lower cuff pressure, thereby reducing the risk of tracheal damage.
Inflation of the cuff with a volume that just prevents an air leak (just-seal volume) is often recommended.
However, this cuff pressure varies greatly. Prevention of excessive cuff pressure may reduce the incidence of
tracheal damage, vocal cord dysfunction from recurrent laryngeal nerve palsy, and sore throat after surgery.
Because palpation is not a good guide to cuff pressure, use of a monitor to maintain cuff pressure in the


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range of 25 to 30 cm H2O is recommended. [51]

Cuff pressure can change after initial inflation. Inhaled N2O diffuses into tracheal tube cuffs that have been
inflated with air and increases the volume and pressure within the cuff enough to cause tracheal lesions and
an increased incidence of sore throat. A leak in the cuff or valve or a reduction in trachealis muscle tone can
lower cuff pressure and increase the risk for pulmonary aspiration. Early detection of both low and high
pressure is important.
A properly inflated cuff protects against massive pulmonary aspiration, but silent aspiration (micro-aspiration)
of pharyngeal contents occurs along channels between folds in the cuff and is a major contributor to
ventilator-associated pneumonia in intensive care. New materials and cuff designs attempt to eliminate cuff
channels and may help prevent micro-aspiration.

Tracheal Intubation
Tracheal intubation (insertion of the tracheal tube) is an essential skill in anesthetic practice. Indications for
tracheal intubation are shown in Box 50-5 . There are no absolute contraindications to tracheal intubation.
Box 50-5

Indications for tracheal intubation

Surgical and Anesthetic Indications
Surgical requirement for neuromuscular blocking drugs, e.g., abdominal surgery
Airway access shared with the surgeon, including ear, nose, and throat surgery
Patient position in which access to the airway is restricted or precludes rapid tracheal intubation,
e.g., lateral, prone
Predicted difficult airway
Risk of aspiration of gastric contents or blood, e.g., upper gastrointestinal obstruction or sepsis,
facial trauma, bleeding into the respiratory tract from any cause
Surgery that impairs gas exchange
Prolonged surgery
Other airway techniques ineffective
Critical Illness
Inability to protect the airway, e.g., coma from any cause
Impaired respiratory function (hypoxemia or hypercapnia) unresponsive to noninvasive
Prevention of hypercapnia, e.g., raised intracranial pressure

Principles of Clinical Practice of Tracheal Intubation

The incidence of complications should be minimized by using best practice. [6] Adequate personnel, drugs,
and equipment must be available. Four principles are central to prevention of complications [52] :

Maintenance of oxygenation must take priority over all other issues. Preoxygenation should be
performed before induction of anesthesia. [6] Mask ventilation should be used between attempts at
tracheal intubation.


Trauma must be prevented. The first attempt at tracheal intubation should be performed under
optimal conditions (including patient position, preoxygenation, and equipment preparation). [53] The
number of attempts with blind techniques should ideally be zero and certainly not more than four.


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The anesthesiologist should have backup plans before starting the primary technique [6] and the
skills and equipment needed to execute these plans. When unanticipated difficulty occurs in nonlifesaving surgery, the safest plan is to terminate attempts at tracheal intubation, awaken the patient,
and postpone surgery.


The anesthesiologist should seek the best help available (call for help) as soon as difficulty with
tracheal intubation is experienced.

Intravenous access is secured (occasionally achieved only during inhaled induction of anesthesia) and
standard monitoring is established. The patient should be in the optimal position. Time spent adjusting the
position after induction of anesthesia may delay successful tracheal intubation, prolong the time at risk for
pulmonary aspiration, and increase the risk for hypoxemia or airway trauma.

Nasotracheal Intubation
Nasotracheal intubation (NTI) is necessary when the oral route is not possible (e.g., limited mouth opening)
or would impede surgical access. NTI was formerly considered the technique of choice for resuscitation, but
orotracheal intubation using the rapid-sequence technique is now usually the first choice. NTI has been used
in critical care as an alternative to tracheotomy because it is better tolerated than oral intubation. However the
tube used must be longer and narrower than oral tracheal or tracheotomy tubes so that airway resistance is
greater and therapeutic aspiration of pulmonary secretions is more difficult. Problems associated with
prolonged duration of NTI include nasal damage, local abscesses, otitis media, and sinusitis. The nasal route
is contraindicated in patients with a history (old or new) of basal skull fracture or surgery. Nevertheless, if
there is no alternative, this infrequent complication may be less likely when a catheter is used as a guide.
The technique of NTI is influenced by the need to minimize the incidence of complications peculiar to this
route, including cuff tears, damage to the nasal cavity (epistaxis, fractured turbinates, avulsed nasal polyps,
septal abscess) and nasopharynx (avulsed adenoids). It is beneficial to use vasoconstrictors to shrink the
mucosa of both nasal cavities before passage of the tube. Another complication is a consequence of the right
angle through which the tube must turn when it passes from the nasal cavity into the oropharynx. The tube
may impact on and tear the mucosa of the posterior nasopharynx and pass submucosally. This complication
is less likely if a soft catheter is first passed into the oropharynx and then used as a guide. Tube factors that
reduce the risk of trauma include diameter not larger than 7.5-mm ID for men and 7.0-mm ID for women,
warming before insertion, and use of a soft tip. The tube is passed directly backward along the floor of the
nose. Resistance to nasal passage may be overcome by gentle rotation or use of a narrower tube or the
other nasal cavity. It is important to be gentle and stop if abnormal resistance is met. The risk of damage may
be reduced by passage through the nasal cavity under vision with an FFL.
Blind nasal intubation was first used in patients breathing spontaneously under deep inhaled anesthesia but
can also be performed in awake patients under topical anesthesia. Tube advancement is guided by changes
in breath sounds at the proximal end of the tube (amplification by a whistle can be very helpful) and by
external palpation of the larynx. Cessation of breath sounds indicates that the tip of the tube has entered the
esophagus, piriform fossa, or vallecula. The tube is withdrawn until breath sounds are heard, the head and
neck position is adjusted, and the tracheal tube is then readvanced. Temporary inflation of the cuff when in
the oropharynx may improve success rates. [54] If the tube is held up at the larynx, head flexion can help the
tracheal tube enter the trachea by improving alignment with the trachea. Blind nasal intubation during
spontaneous ventilation may still be useful when an FFL is not available. Attempted blind NTI in an apneic
patient risks trauma and failure.
NTI is often performed after the administration of intravenous anesthetics and NMBDs. A direct laryngoscope
is used to facilitate NTI under vision and is inserted once the tip of the tube has reached the oropharynx.
Magill forceps are frequently used to grasp the tracheal tube (avoiding the cuff) and guide it into the trachea.
An assistant then advances the tube. Rigid indirect laryngoscopes (RILs) can facilitate NTI under vision in
patients in whom this is not possible with direct laryngoscopes.

Direct Laryngoscopy: Theoretical Basis

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depends on achieving a line of sight from the maxillary teeth to the larynx. The tongue and epiglottis are the
anatomic structures that intrude into the line of sight. Management of the tongue and epiglottis is therefore
central to successful direct laryngoscopy. Before the laryngoscope is inserted, the patient is normally placed
in the sniff position (see later). The direct laryngoscope is then used to displace the tongue and epiglottis
out of the line of sight. The tongue is displaced horizontally (normally to the left) from the line of sight, the
hyoid bone and attached tissues are moved anteriorly, and the epiglottis is elevated directly or indirectly to
reveal the larynx. The force applied to the laryngoscope handle should lift the hyoid bone and attached
tissues parallel to the line of sight. Adequate lifting force, which may cause considerable tissue distortion, [7]
[55] [56] is a key factor in successful direct laryngoscopy. [7] [56] It is important to achieve the best possible view
of the larynx without causing tissue trauma. It is not always possible to achieve line of sight with direct
The theoretical basis of the head and neck position used for direct laryngoscopy was attributed to the need to
align the axes of the oral cavity, pharynx, and larynx on the basis of a radiology study. Magnetic resonance
imaging in awake patients has been used to challenge this hypothesis, but the conclusions have been
controversial. Understanding of management of the tongue and the epiglottis is more likely than the axis
alignment hypothesis to improve direct laryngoscopy technique.
The sniff position ( Fig. 50-6 ) is usually the best starting position for direct laryngoscopy. In the sniff
position, the cervical spine below C5 is relatively straight, there is increasing flexion from C4 to C2, and the
head is fully extended (occipito-atlanto-axial complex). [57] Neck flexion between C2 and C4 is achieved by
elevation of the head. No statistical advantage of the sniff position over simple head extension was found in
one study, except in the presence of obesity or limited head extension. [26] However, the sniff position
facilitated a view of the larynx in 4% of patients in whom this was not possible with simple head extension.
The sniff position also improves pharyngeal airway patency in patients with obstructive sleep apnea. Head
extension facilitates insertion of the laryngoscope, reduces contact between the laryngoscope and the
maxillary teeth, improves the view of the larynx, and facilitates full mouth opening. Head extension should be
used unless there is a contraindication.


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Figure 50-6 Sniff position. A volunteer positioned on the Popitz pillow (DermaCare, Louisville, KY) demonstrates cervical
flexion and a small degree of atlanto-occipital extension. The flexion aligns the laryngeal and pharyngeal axes. Further extension
of the head results in the true sniffing position.

Macintosh Laryngoscope and Technique of Orotracheal Intubation

The Macintosh curved laryngoscope is radically different from the preexisting straight laryngoscopes. In
particular, the long axis of the blade is curved, the cross section is a right-angled Z section, the web and
flange are bulky, the tip is atraumatic, and the light bulb is shielded by the web. However, Macintosh's key
innovation was his novel technique of indirect elevation of the epiglottis, achieved by tensioning the
hyoepiglottic ligament after the tip of the laryngoscope was positioned in the vallecula. This technique is the
key to success of the Macintosh laryngoscopeand its fundamental flaw. When it works well, the epiglottis is
elevated completely and lies behind and along the posterior surface of the laryngoscope blade. However, it is
not possible to position the Macintosh laryngoscope correctly in some patients. Minor difficulty results in
partial elevation of the epiglottis, erroneously described as a floppy epiglottis, and major difficulty leads to
complete failure to elevate the epiglottis with the consequence that the vocal cords cannot be seen.
Tracheal intubation is normally achieved with a rapid sequence of maneuvers in which all components of a
complex technique merge into one another. The best technique will develop if all components are optimized.
The three component steps of direct laryngoscopy are insertion of the laryngoscope, adjustment of its
position and lifting force, and use of other maneuvers to optimize the view of the glottis.
The sniff position is used. Full mouth opening facilitates insertion of the laryngoscope. It is inserted from the
right side of mouth and to the right of the tongue while taking care to not trap the lips between the
laryngoscope blade and the teeth. The laryngoscope is advanced and simultaneously moved into the midline
to displace the tongue to the left. Progressive visualization of anatomic structures minimizes the risk of
trauma. The epiglottis is the first key anatomic landmark. The tip of the laryngoscope is advanced into the
vallecula, and the epiglottis is elevated indirectly by applying a force that tensions the hyoepiglottic ligament.
Elevation of the epiglottis is optimized and a further lifting force is applied to the laryngoscope to achieve the
best view of the larynx ( Fig. 50-7 ). It is very important not to lever on the maxillary teeth because this may
cause dental damage [58] and reduce the view of the larynx. If visualization of the larynx cannot be achieved
without pressure on the teeth, use of this laryngoscope should be abandoned and another technique of
tracheal intubation used.


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Figure 50-7 Macintosh laryngoscope in position. The laryngoscope tip is in the vallecula, the hyoepiglottic ligament is tensioned
and the epiglottis has been elevated indirectly so that it lies along the posterior surface of the laryngoscope. (From Key Topics in
Airway Management, Cambridge University Press.)

When a good view of the larynx is achieved, the vocal cords, aryepiglottic folds, posterior cartilage, and
interarytenoid notch can be identified ( Fig. 50-8 ). The view should be optimized to facilitate passage of the
tracheal tube. If the view of the larynx is poor, it is important to check that the basic technique has been
performed optimally and other maneuvers used ( Box 50-6 ). External laryngeal manipulation (better
described as bimanual laryngoscopy, which implies internal movement of the laryngoscope with external
manipulation of the larynx), performed by the anesthesiologist who guides an assistant ( Fig. 50-9 ),
consistently improves the laryngeal view. It is a key maneuver.


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Figure 50-8 Schematic view of the glottic opening during direct laryngoscopy when the epiglottis is elevated with a curved or
straight laryngoscope blade. The glottic opening is recognized by its triangular shape and the pale, white vocal cords. (From
Stoelting RK, Miller RD: Basics of Anesthesia, 3rd ed. New York, Churchill Livingstone, 1994.)

Box 50-6

Maneuvers Used to Optimize the View at Direct Laryngoscopy

Maximum head extension

Tongue entirely to the left of the laryngoscope
Optimal depth of insertion of the laryngoscope
Strong lifting force applied in the correct direction to the laryngoscope
External laryngeal manipulationapplied initially with the right hand of the anesthesiologist


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Figure 50-9 Bimanual laryngoscopy (external laryngeal manipulation). The anesthesiologist guides the position and pressure
exerted by the assistant's hand on the larynx to maximize view of the vocal cords. The left hand of the anesthesiologist, which
holds the laryngoscope handle, is omitted.

Tracheal Tube Passage with Successful Macintosh Laryngoscopy

The view of the vocal cords is maintained while the anesthesiologist guides the tube under vision between
the vocal cords. Passage of the tube from a position posterolateral to the larynx facilitates observation of
progress of the tracheal tube toward and between the vocal cords. Steering of the tube and passage under
vision are facilitated if the tube has the optimal ice hockey stick shape, normally created by the use of a
stylet within the tube. The tracheal tube is advanced until the cuff is about 2 cm distal to the vocal cords. This
position is important inasmuch as more proximal positions may cause cuff leaks and pressure on the
recurrent laryngeal nerve. [5] The cuff is inflated to slightly higher than the just-seal pressure, and the correct
position of the tube is confirmed. Cuff pressure is then adjusted to 25 to 30 cm H2O.
If only the posterior portion of the vocal cords can be seen, including the interarytenoid notch, passage of the
tracheal tube may be awkward but is not difficult. Either a styletted tracheal tube or passage of an introducer
(bougie) under vision, followed by passage of the tracheal tube over the introducer, may be used. Both are
reliable visual techniques.
Difficulty with the Macintosh Technique

Difficulty with tracheal intubation is predominantly a consequence of failure to see the larynx. [53] The efficacy
of direct laryngoscopy is measured in terms of the best view of the larynx achieved. The most widely used
scale is that described by Cormack and Lehane (CL) ( Fig. 50-10 ). The definitions used are grade 1, most of
the glottis is visible; grade 2, only the posterior extremity of the glottis is visible; grade 3, no part of the glottis
and only the epiglottis is visible; and grade 4, not even the epiglottis can be seen. The most useful
modification is a subclassification of grade 3 into 3a when the epiglottis can be lifted from the posterior


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pharyngeal wall and 3b when it cannot be lifted. [59] This modification of grade 3 is important in clinical
practice because the introducer technique does not work well in the grade 3b situation. [59] All the definitions
apply to the best view that can be achieved, which implies the use of external laryngeal manipulation
whenever the initial view is unsatisfactory.

Figure 50-10 Laryngoscopy view grades.

The complexity of tracheal intubation may be recorded with the intubation difficulty scale (IDS), [60] a
numerical score based on seven parametersnumber of attempts, number of operators, number of
alternative techniques, laryngeal view, lifting force required, application of laryngeal pressure, and vocal cord
mobilityassociated with difficult intubation. It does not include the duration of attempts. The IDS alone does
not indicate the cause of the difficulty, and it is more important to communicate the scores for the individual
elements of the IDS. A record of all these elements plus the duration of attempts is desirable after every
tracheal intubation.
A 2% or lower incidence of CL grade 3 or 4 has been recorded. However, other large prospective studies,
excluding patients with obvious [7] or anticipated [61] airway difficulty, have shown an incidence of CL grade 3
or 4 of 6.1%, [7] 10.1%, [61] or higher. External laryngeal manipulation was not used in most of these studies,
so the clinically important incidence was probably half that reported. Difficulty with laryngoscopy has probably
become more frequent as a consequence of patient factors such as increasing age, obesity, and modern
dentistry. Anesthesiologists may also have become more reluctant to apply high lifting pressure to the
laryngoscope as a result of awareness of airway trauma and the availability of alternative techniques.
Not all of the factors that contribute to difficulty with direct laryngoscopy have been identified. Factors that
impair insertion of the laryngoscope, lateral displacement of the tongue, or elevation of the epiglottis will
impair the efficacy of direct laryngoscopy. Anatomic causes include limited mouth opening, awkward
dentition, hypoplastic mandible, impaired TMJ function, and limited head extension. A final common pathway
of difficulty with the Macintosh laryngoscope was suggested by a soft tissue radiology study of laryngoscopy.
[62] In patients with known difficult laryngoscopy the tongue could not be completely displaced and part was
trapped between the tip of the laryngoscope and the hyoid bone. The tip of the laryngoscope could not enter
the vallecula and advancement of the laryngoscope displaced the epiglottis further into the line of sight. Thus,
indirect elevation of the epiglottis, the novel feature of the Macintosh technique, is also its fundamental flaw.
Blind Endotracheal Intubation with the Macintosh Laryngoscope

If the larynx cannot be seen, it is not possible to intubate the patient under vision with the Macintosh
laryngoscope, and failure and soft tissue trauma are potential risks. The anesthesiologist must decide
whether to use a blind technique with the Macintosh laryngoscope, abandon further attempts at tracheal


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intubation and awaken the patient, or use an alternative visual technique of laryngoscopyprovided that
skills have been developed. Use of an SAD for elective surgery in these patients when tracheal intubation
had been the first choice places them at risk if the airway becomes obstructed.
Blind techniques (styletted tracheal tube or introducer) have been the first alternative used when the larynx
cannot be visualized with the Macintosh laryngoscope. Introducers, such as gum elastic bougies with an
angulated tip, are passed (introduced) into the trachea and then used as a guide for passage of the tube. The
introducer technique is relatively simple and incorporates verification of its blind passage down the trachea.
[52] It can be divided into three parts: passage of the introducer, confirmation of tracheal position, and
passage of the tube over the introducer into the trachea. The laryngoscope is kept in the midline, and the
anesthesiologist estimates the probable location of the larynx and attempts to pass the tip of the introducer
behind the epiglottis and blindly between the vocal cords and into the trachea. Gentle technique should
minimize trauma and facilitate verification of passage into the trachea. A sensation of clicks and distal holdup
have been detected in at least 90% of correct intratracheal placements. Successful positioning of the
introducer in the trachea is followed by passage of the tracheal tube over the introducer and into the trachea.
This sometimes proves difficult. [52] The laryngoscope should be kept in place during passage of the tracheal
tube, and 90-degree anticlockwise rotation of the tube is often effective. The use of small tracheal tubes
facilitates passage of the tracheal tube. Other tracheal tube factors affecting the success of passage are
considered in the section on use of the FFL. When the tube has been passed and the introducer removed,
tracheal position must be confirmed. The blind introducer technique has a high success rate, such as 90% in
a prospective study that permitted a maximum of two attempts. [63] However, there are many case reports of
failure, and the technique does not work well when the epiglottis cannot be elevated from the posterior
pharyngeal wall. [59]
The introducer technique was developed to overcome problems with the Macintosh technique before there
was evidence of the efficacy of alternative techniques. There is now evidence of high success rates of
tracheal intubation under vision with the straight laryngoscope, [45] FFL, [46] and RIL [47] when the Macintosh
technique fails. Multiple blind attempts at tracheal intubation were often made in the past but are associated
with morbidity and mortality. [43] [64] [65] Eventual tracheal intubation after several attempts with blind
techniques should be regarded not as success but as a near miss.
The role of blind techniques in modern practice should be questioned. The anesthesiologist should be aware
that airway difficulty can be a consequence of friable lesions such as lingual tonsil hypertrophy. [3] Use of
blind techniques in such unpredictable situations can cause airway obstruction. Some centers do not use
blind techniques, [46] [47] others limit the number of attempts to two, [63] and all should seek to emulate this
enlightened practice. If a few attempts with alternative techniques are not successful, elective surgery should
be postponed, the patient awakened, and subsequent awake flexible fiberoptic laryngoscopy scheduled.
Modifications of the Macintosh laryngoscope

Many variations have been described, most without data about their efficacy. A Macintosh-type laryngoscope
with a hinged tip that flexes when a lever on the handle is depressed was introduced by McCoy. It works well
in simulated difficult laryngoscopy, and there have been many clinical reports of success when the glottis
could not be visualized with the Macintosh laryngoscope. However, an angulated straight laryngoscope
performed much better than the McCoy in clinical unanticipated difficult intubation, and there have been many
reports of failure of the McCoy laryngoscope to achieve a view of the glottis.

Straight Laryngoscope
Laryngoscopy for tracheal intubation was first performed with the straight laryngoscope, which remains the
diagnostic and therapeutic laryngoscope used by ENT surgeons. Many studies [45] have reported successful
tracheal intubation under vision with the straight laryngoscope in patients in whom intubation proved
impossible with the Macintosh laryngoscope. Corroborative evidence of the value of this technique comes
from many reports of successful use of the ENT straight laryngoscope and the rigid bronchoscope in such
The mechanism of the greater efficacy of the straight laryngoscope is probably both improved control of the
tongue and more reliable elevation of the epiglottis and is consistent with the reduced force and head


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extension needed with the straight laryngoscope. [55] The straight laryngoscope is of particular value with
laryngeal lesions (including lingual tonsil hypertrophy) and in patients with a hypoplastic mandible. It is useful
in some patients with awkward dentition, particularly the presence of a gap in the right upper dentition.
Mastery of the straight laryngoscope is an asset to any anesthesiologist.
The technique described here, the paraglossal technique, affords optimum control of the tongue. Initial
preparation for tracheal intubation is identical to that used with the Macintosh laryngoscope. Head extension
is as important as in the Macintosh technique. It is essential to displace the entire tongue to the left of the
laryngoscope. The laryngoscope is inserted lateral to the tongue and advanced carefully along the
paraglossal gutter between the tongue and tonsil. Application of continued moderate lifting force to the
laryngoscope handle helps maintain lateral displacement of the tongue and reduces contact with the
maxillary teeth. As the laryngoscope is advanced, the epiglottis comes into view and the tip of the
laryngoscope is passed posterior to it. The optimal position of the tip of the straight laryngoscope is in the
midline of the posterior surface of the epiglottis, close to the anterior commissure of the vocal cords ( Fig. 5011 ). This position achieves good control of the epiglottis and facilitates passage of the tracheal tube. The
direction of force applied to the handle of the straight laryngoscope is at right angles to the straight
laryngoscope blade (and in line of sight of the larynx). Under no circumstances should levering action be
applied to the teeth. Not only does this risk dental damage, but it also degrades the view. If a good view
cannot be achieved, a different technique of laryngoscope or tracheal intubation should be used.


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Figure 50-11 Straight laryngoscope in position. The laryngoscope tip is posterior to the epiglottis, which is elevated directly. The
tip of the laryngoscope is close to the anterior commissure of the vocal cords. (From Key Topics in Airway Management,
Cambridge University Press.)

If the larynx is not visible, it is probable that the tip of the laryngoscope is located in the vallecula, piriform
fossa (usually the right), posterior pharyngeal wall, or the esophagus. The basic checks and maneuvers for
direct laryngoscopy techniques (see Box 50-6 ) are performed. Bimanual laryngoscopy, including lateral
movement of the larynx (regularly used by ENT surgeons), is particularly important. Direct tracheal tube
passage with the Miller laryngoscope can be awkward. The visual introducer technique is useful whenever it
proves difficult to guide the tube to the larynx.
The Miller laryngoscope is popular because its low profile facilitates insertion and positioning, but there are
some problems. The tip has a small point of contact with the posterior surface of the epiglottis, so there is a
risk of trauma and unstable elevation of the epiglottis. Precise positioning is difficult because the tip is not
visible. The major problem with the Miller laryngoscope is that its cross section impedes passage of the
tracheal tube. Straight laryngoscopes have been designed to overcome problems with the Miller


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laryngoscope. The Belscope is a narrow angulated straight laryngoscope with a low profile and an atraumatic
tip that was designed to reduce contact with the maxillary teeth. The efficacy of the Belscope when the larynx
cannot be seen with the Macintosh laryngoscope has been confirmed. The C-shaped cross section of the
Henderson laryngoscope facilitates the passage of tracheal tubes.

Indirect Laryngoscopy: Theoretical Basis

In some patients, direct laryngoscopy cannot provide a view of the larynx. Optical devices have been
developed to facilitate tracheal intubation under vision with technology that transmits the image from a distal
lens to the proximal end of the device. Because the proximal end of the line of sight is transferred from above
the maxillary teeth to the laryngopharynx, a view of the larynx is obtained from a position that cannot be
achieved with direct laryngoscopy. Visualization of the larynx without the need to distort the tissues (displace
the tongue to the left) or to use head extension becomes possible. Lower laryngoscope lifting force may be
needed than is the case with direct laryngoscopy. Consequently, these techniques can be used readily with
topical anesthesia in an awake patient. Indirect laryngoscopy allows tracheal intubation under vision in
patients in whom this is not possible with direct laryngoscopy. Many devices have been designed, and
features of the ideal technique are shown in Box 50-7 . No single technique meets all these criteria.
Box 50-7

Characteristics of the ideal laryngoscope technique for tracheal intubation

Facilitates rapid tracheal intubation under vision

Used with the patient in a neutral position
Minimal tissue distortion required
Tracheal tube passage integrated in design and technique
Few steps involved in a technique that is intuitive
Competence can be gained rapidly
Equipment simple, robust, portable, and inexpensive
High success rate in all clinical situations
Preparation time should be minimal
Sterilization easy and effective (or the device should be single-use type)
Illumination good
Optical device characteristics
Sufficient optical quality
Fogging of lens unlikely
Separation of anatomic structures beyond the distal lens is essential to provide adequate vision. Separation
may be achieved by maneuvers such as jaw thrust (not normally necessary in an awake patient),
displacement by the device itself (many RILs), or simultaneous use (frequently in the case of optical stylets
[OSs]) of a laryngoscope. Problems with condensation, blood, and secretions are common to all these
devices. Modern indirect laryngoscopes can be divided into flexible (FFLs) and rigid devices (RILs). Each
group has advantages and disadvantages.

Flexible Fiberoptic Laryngoscope

The FFL uses flexible optical fibers to transmit images from a distal lens as it is steered under vision toward
the larynx and into the trachea. [66] A typical FFL is shown in Figure 50-12 . The insertion cord contains
bundles of optical fibers that transmit the image, a different group of optical fibers that transmit light to the


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distal end, and cables from a control lever in the handpiece that flex and extend the distal section. The hollow
channel can be used for aspiration of secretions or instillation of local anesthetic. The simplest FFLs have a
proximal eyepiece. The image can be displayed on a monitor by attaching a camera to the eyepiece or by
using an FFL with an integral camera. Some models have a distal video chip from which the image is
transmitted electronically to a video display, so a more accurate term is flexible video laryngoscope, but
they function as FFLs and this term is used for simplicity. Use of video monitors incurs greater expense than
reliance on eyepieces, but they facilitate teaching and ease of use and may improve success rates.

Figure 50-12 Flexible fiberoptic laryngoscope.

The FFL is the most versatile laryngoscope ( Box 50-8 ) for tracheal intubation and can facilitate intubation
that could not be achieved with any other technique. Some advantages are shown in Box 50-9 . A high
success rate can be achieved. [67] [68] Its use in patients with anticipated difficult intubation significantly
reduces the number of complicated intubations and the incidence of intubation trauma and postoperative
upper airway edema. The FFL in expert hands is well tolerated by an awake patient. Awake flexible fiberoptic
laryngoscopy is the safest noninvasive means of securing a critical airway. [68] It is indicated in many
situations, some of which are presented in Box 50-10 . A low threshold for use of awake flexible fiberoptic
intubation in emergency patients is particularly important inasmuch as the option of postponing surgery and
awakening the patient is not available.
Box 50-8

Versatility of the Flexible Fiberoptic Laryngoscope

Flexible and steerable

Minimal tissue pressure and trauma
Continuous visualization
Oral or nasal route possible
Other intubating devices may facilitate combination techniques
Visual confirmation of the depth of intubation on withdrawal
Box 50-9

Advantages of Awake Patient State for Flexible Fiberoptic Laryngoscopy


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Spontaneous breathing continues

Oxygenation and ventilation maintained
Intubation easier
Anatomy and muscle tone preserved
Phonation as a guide
Airway protection preserved
Options preserved
Box 50-10

Indications for Flexible Fiberoptic Laryngoscopy

Anticipated difficult tracheal intubation

Anticipated difficult mask ventilation, including seep apnea
Anticipated difficult rescue technique
Confirmation of tracheal tube position
Diagnosis of malfunction of a supraglottic airway device
Cervical spine instability (the rigid indirect laryngoscope is an alternative)
Positioning of a double-lumen tube and bronchial blocker
Assessment of swelling or trauma after difficulty with airway management
Tracheal tube change (between the nasal and oral routes)
Intensive care use, including aspiration of secretions and confirmation of the dilatational
tracheotomy site
Neither deep sedation nor general anesthesia should be used when the airway is compromised. [27] When the
patient is alert, ventilation, oxygenation, and airway protection are maintained. Normal pharyngeal tone is
preserved, so there is sufficient space between structures to facilitate vision several centimeters beyond the
distal lens. Phonation, which can help identify the larynx, is possible. Options are preserved. Because some
patients will not tolerate awake flexible fiberoptic laryngoscopy, sedation or general anesthesia may be
necessary, but there are risks of hypoventilation, upper airway obstruction, and hypoxemia. The ideal
sedative would have little effect on spontaneous ventilation and allow patients to protect their airway.
Dexmedetomidine may provide effective and safe sedation in apprehensive or combative patients.
Remifentanil infusions have been used, but careful monitoring is essential to prevent hypoventilation and

The technique is summarized in Box 50-11 . The patient's position may be supine, semisupine, or sitting
( Fig. 50-13 ), and the anesthesiologist may face or work from behind the patient. These choices are
influenced by clinical requirements and personal preference. Use of the fully upright sitting position has been
recommended when pulmonary aspiration is a consideration.
Box 50-11


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Flexible Fiberoptic Laryngoscopy Technique

Drying agent
Effective topical anesthetic
Equipment check: lenses clean and focused, antifog agent applied
Tracheal tube mounted
On the flexible fiberoptic laryngoscope for the nasal route
Within the oral airway for the oral route
Patient position: supine, semisitting, or sitting
Rapport: full explanation
Flexible fiberoptic laryngoscope technique
Insertion cord kept straight and the scope maneuvered in three planes
Tip flexion-extension, rotation, and advance-withdrawal
Secretions aspirated
White-out, red-out, or loss of targetwithdraw, indentify structures, readvance
Targets (epiglottis, vocal cords, tracheal cartilages, carina) kept in the center of view as
the flexible fiberoptic laryngoscope is advanced
Advance to close to the carina
Tracheal tube passed over the flexible fiberoptic laryngoscope
Tube position confirmed and secured and anesthesia induced

Figure 50-13 A flexible fiberoptic laryngoscope inserted through a Bermann airway in a patient in the sitting position. An epidural
catheter attached to a syringe has been passed through the working channel. The tracheal tube has been placed within the


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airway and the fiberoptic laryngoscope is advanced under vision between the vocal cords and into the trachea.

The FFL may be passed through the nose or mouth. The nasal cavity acts as a conduit that provides good
alignment with the larynx as the FFL passes from the nasal cavity to the pharynx. Use of conduits such as
tubular oropharyngeal airways [69] (e.g., Williams, Ovassapian, Bermann II), the intubating LMA (ILMA), or the
AIT through other SADs may facilitate passage of the FFL through the mouth. These techniques keep the
FFL in the midline and deliver its tip to the laryngopharynx. They also protect the FFL from biting. The gag
reflex is more troublesome with the oral than with the nasal route. Experience in other fields of medicine and
dentistry shows that gagging can be managed by hypnosis, control of hyperventilation, acupressure, or
sedation with nitrous oxide or propofol.
Proper preparation contributes greatly to successful awake use of the FFL. Rapport with the patient and good
topical anesthesia of the airway are important. A drying agent (such as atropine or glycopyrrolate) may be
given before the application of topical anesthesia to the airway to increase its efficacy and minimize problems
with visualization caused by secretions. A vasoconstrictor is sprayed into the nose when the nasal route is
planned. Equipment preparation includes checking the optics, cleaning and antifogging of the distal lens,
passage of an epidural catheter through the working channel, and lubrication of the insertion cord. The
tracheal tube is normally mounted on the FFL before NTI but may be positioned with the tip in the oropharynx
before passage of the FFL.
General care of the patient during intubation is important, particularly maintenance of airway patency and
oxygenation. [66] Insufflation of oxygen down the working channel of the FFL has been advocated to increase
FIO2 and keep the lens clear of secretions but has caused barotrauma and is not advisable. Oxygen should
be administered nasally or via facemask, and the oximeter beep should be audible.
The principles of FFL manipulation are simple. [66] The basic maneuvers of flexion and extension of the tip
combined with rotation of the insertion cord make it possible to steer the FFL under vision around tissues as it
is moved toward the larynx and trachea. The external portion of the insertion cord must be kept straight
during manipulation so that rotation of the handpiece is transmitted to the distal end. Movements should be
gentle and fine. The FFL is advanced while keeping the target in the center of the image as the FFL moves
toward the epiglottis, vocal cords, tracheal rings and muscle, and carina. The FFL is passed into the distal
portion of the trachea and the tracheal tube then passed over it into the trachea as the patient is asked to
inhale deeply. As soon as tracheal intubation is confirmed, the FFL should be withdrawn in an awake patient
because respiration will be significantly obstructed while the FFL remains within the tracheal tube. However,
premature removal of the FFL during passage of the tracheal tube can result in dislodgement of the tube and
esophageal intubation. Tracheal intubation is confirmed by visualization of the carina close to the end of the
tracheal tube, and this distance is adjusted to 3 to 4 cm. Additional confirmation of tracheal intubation with
capnography is mandatory before anesthesia is induced.
The FFL technique is straightforward in most patients but may be difficult in those with distorted anatomy or
very limited space. Jaw thrust may help in the latter situation. An opaque red view implies contact of mucosa
or blood with the lens, and a white view is caused by secretions. If sight of the target is lost, the FFL should
be withdrawn, the target identified, and the FFL advanced again.
In situations in which use of the FFL alone proves difficult, combination with other techniques may be
successful. A retrograde guide can be threaded up the working channel of an FFL on which the tube had
been mounted and the combined assembly then advanced to the cricothyroid membrane before the guide is
removed. Alternatively, passing the FFL alongside a retrograde guide within a tracheal tube and then
advancing the FFL to the carina to act as an introducer may be particularly reliable. Direct or indirect rigid
laryngoscopy may be used with the FFL. Use of a capnograph as a guide has been described. [70] Use with
SADs is described later.
Tracheal Tube Passage Issues

Difficulty passing tracheal tubes over a properly positioned FFL is common and can result in hypoxemia or
airway trauma and be a threat to life. [50] The principal sites that obstruct passage of the tracheal tube are the
interarytenoid notch and the right arytenoid cartilage and epiglottis, plus obstruction within the nasal cavity


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when that route is used. [50] A technique involving withdrawal of the tracheal tube 1 to 2 cm, 90-degree
anticlockwise rotation, and readvancement often achieves tracheal intubation in these cases. [50] Jaw thrust
may help steer the FFL into the trachea but can obstruct subsequent passage of the tracheal tube, so the
thrust should be reduced after the tracheal tube has passed the larynx. [50] Force must not be used during
attempts to pass the tracheal tube.
All measures should be taken to ensure that the first attempt at passage of the tracheal tube is likely to be
successful. [50] Tracheal tube factors that can increase success of passage include a small gap between the
tracheal tube and the FFL [50] and the type of tracheal tube. [50] Although use of a warmed standard tracheal
tube has been recommended, it is not clear how long it retains increased softness, there is no evidence that it
is better than an armored tracheal tube, and the risk of kinking may be increased. There is some disputed
evidence that armored tubes pass more readily than standard tracheal tubes over the FFL into the trachea.
Tracheal tubes with tips modified to facilitate passage into the trachea are of proven value and may be the
current tracheal tubes of choice.
Limitations of the Flexible Fiberoptic Laryngoscope in Unanticipated Difficult Intubation

Use of the FFL in anesthetized patients immediately after failure of direct laryngoscopy can be difficult ( Box
50-12 ). The flexibility that contributes to the versatility of the FFL in elective patients can be disadvantageous
because rapid control of the tip's position is not possible. Use of the nasal route in an unprepared patient
risks epistaxis, which is particularly hazardous in this situation. Oral fiberoptic intubation is preferable, but jaw
thrust, tongue traction, or concomitant use of a direct laryngoscope may be required unless a conduit is used.
Use of a tubular oral airway can be very successful when staff are well trained. [46] The airway must be kept in
the midline and directed toward the larynx. Fiberoptic intubation through the ILMA or LMAc has been
recommended in guidelines. [52] Use of the FFL through the ILMA is usually successful, but failures do occur.
[71] Use of the Aintree or similar catheter with the LMAc is another good alternative. [72] Use of the FFL in a
patient with an unanticipated difficult airway requires immediate availability of a sterile FFL.
Box 50-12

Problems with the Flexible Fiberoptic Laryngoscope Technique in Unanticipated Difficult

Intubation *

High skill level needed for rapid control of the tip of the laryngoscope
Two skilled practitioners needed
Equipment often not ready (time)
Secretions, edema, and hemorrhage
Airway less open than when awakejaw thrust and/or dedicated oral airway needed
Cricoid pressure impeding entire procedure
Tracheal tube passage difficult
Patient risks: hypoxemia, hypoventilation, and pulmonary aspiration
* Patient anesthetized and paralyzed.

Contraindications and Complications

There are no absolute contraindications to use of awake flexible fiberoptic laryngoscopy. It cannot be
performed without patient cooperation. Awake intubation with the FFL is unlikely to work in the presence of
massive airway bleeding, although the LMA can provide an effective conduit.
The arytenoid cartilage can be displaced, even when tube advancement seems atraumatic. Laryngeal
damage is more likely when multiple efforts at passage of the tracheal tube are made, but such damage is
less frequent and less serious than in patients managed with direct laryngoscopy. Morbidity and mortality


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associated with use of the FFL have been reported in closed claims. [43] Complete airway obstruction during
awake fiberoptic intubation in patients with a critical airway has been reported, but heavy sedation and
incomplete topicalization were blamed. [27] Awake flexible fiberoptic laryngoscopy is safe in a critical airway
when expertly used. [68]

Rigid Indirect Optical Devices

The rigidity of rigid indirect optical devices allows rapid control of the position of the tip of the device at the
expense of reduced versatility in comparison to flexible devices. They are also less expensive and more
robust and portable than the FFL. They may be subdivided into RILs and OSs.
The blade of an RIL can retract tissues to achieve a line of sight from the distal lens, and this ability can be
important when there is little space in the oropharynx and laryngopharynx. OSs are optical devices that fit
inside the tracheal tube.
The term video laryngoscope has been used by manufacturers of devices that differ in many features.
Video laryngoscope is not a good description for these devices because the display is not the key element
in their success. However, video systems have advantages. They are of proven value for teaching flexible
fiberoptic intubation and RIL technique [73] and may improve success rates. Ease of use is better because
anesthesiologists do not need to follow the eyepiece with their head. Observation of structures throughout
insertion and removal is facilitated. The video display facilitates help by assistants, who observe the effect of
manipulations. Video tapes of the intubation can be reviewed later.
Rigid Indirect Laryngoscope

RILs vary greatly in features and technique. Most RILs have a distal curve that is designed to match the
anatomic curve between the oral and pharyngeal portions of the tongue. Technologies used to transfer the
image from the distal lens include lenses and prisms (e.g., Airtraq, TruView), fiberoptics (e.g., Bullard,
Upsherscope, WuScope), and electronic transmission from a video chip to a monitor (e.g., Glidescope,
McGrath, Pentax AWS). They may be used with the head and neck in a neutral or sniff position. The
recommended technique of elevation of the epiglottis may be direct or indirect. Direct elevation is more likely
to be successful in the presence of lingual tonsil hypertrophy or other laryngeal lesions. The technique of
tracheal tube passage is integrated into the design of some RILs. NTI guided by RILs is a very useful
technique that overcomes the problems of passage of the oral tracheal tube inherent in some RILs.
The Bullard laryngoscope, the first RIL, was introduced in the late 1980s. Very high success rates have been
achieved in patients in whom the larynx cannot be seen with the Macintosh laryngoscope. [47] Techniques
can be divided into different stages. The technique with the Bullard laryngoscope is illustrated in Figure 5014 . Most RILs are rotated over the dorsum of the tongue from the oropharynx into the laryngopharynx. Once
the tip of the RIL is in the appropriate position in relation to the epiglottis, a lifting force is applied to elevate
the epiglottis. Visualization of the larynx is optimized by adjustment of the lifting force and position of the RIL.


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Figure 50-14 Insertion sequence for the Bullard laryngoscope. A, Start position with the Bullard handle close to the chest and
the tip within the mouth. B, Midway through rotation of the Bullard laryngoscope. C, Rotation of the Bullard laryngoscope is
complete, with the tip lying on the posterior pharyngeal wall and the handle vertical. The anesthesiologist has used a jaw thrust to
increase space behind the tongue. D, The anesthesiologist seeks and optimizes the view of the larynx. The Bullard laryngoscope
has been moved anteriorly so that the tip lies posterior to and elevates the epiglottis.

The technique of tracheal tube passage depends on the design of the RIL. Integrated tube passage may be
accomplished with either a dedicated stylet attached to the RIL or a channel for the tube. Exit of the tube from
such a stylet or channel is designed to converge with the line of sight a few centimeters distal to the lens. The
tube is guided in a lateral or posterolateral direction to the RIL and is sometimes impeded by the right
posterior cartilage or aryepiglottic fold. This problem can be overcome by manipulating the RIL so that the
vocal cords are to the right of the center of the image and by leaving sufficient space between the tube and
the aryepiglottic fold. An introducer with an angulated tip can be inserted within tubes passed through a
dedicated channel to further facilitate passage into the trachea.
Some RILs do not have an integral tracheal tube passage system, so use of a detached stylet to create an
optimal shape for delivery of the tracheal tube to the glottis is recommended. Both a hockey stick shape and


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a curvature that matches the RIL have been advocated, as have adjustable stylets. Passage of detached
styletted tracheal tubes with RILs is likely to be inherently difficult, but performance improves with experience.
The vector of advancement of oral tracheal tubes into the larynx is about 90 degrees from the direction of the
force applied to the proximal end of the tube. Although good results have been reported, tracheal intubation
can fail when the larynx is visible and multiple attempts at passage of the tracheal tube have been required.
[74] Damage to the palatopharyngeal folds and palate by blind passage of detached styletted tracheal tubes
through the mouth has been described. A technique that involves looking in the mouth when passing the
Glidescope, at the monitor when optimizing its position, at the mouth again when passing the styletted
tracheal tube into the pharynx, and then at the monitor when passing the tracheal tube into the trachea has
been recommended [75] to reduce the risk of soft tissue damage.
There is good evidence of the efficacy of RILs in many situations. They should be accepted as a necessary
alternative to direct laryngoscopy and should be included in plan A (initial tracheal intubation plan) for the
management of unanticipated difficult intubation. They may also be useful in anticipated difficult direct
laryngoscopy in an uncooperative patient, when an FFL is not available, and possibly when a minor degree of
difficulty with direct laryngoscopy is anticipated. Their advantages of minimal neck movement and more
reliable view of the larynx than with direct laryngoscopes are strong indications for use in patients with an
unstable cervical spine if an FFL is not available. [57] [76]
Optical Stylets

OSs are robust and portable stylets that incorporate a distal lens and optical system. They may be rigid or
malleable or have a tip that can be flexed and extended. The tracheal tube is mounted on the stylet and
advanced under vision for a variable distance into the larynx. The stylet is then held in place while the
tracheal tube is advanced into the trachea. Midline or lateral routes may be used. [77] OSs cannot retract
tissues, and failure to identify anatomic structures has been reported. Vision beyond the lens may be
improved by separating the pharyngeal structure with the jaw-thrust maneuver, [76] [77] displacing the tongue
and opening the pharynx with a Macintosh or McCoy laryngoscope, or using anterior traction on the tongue.
[77] Use of jaw thrust combined with a direct laryngoscope may be necessary in the most difficult patients.
Recessed positioning of the tip within the tracheal tube may help keep secretions or blood off the tip. A high
success rate in unanticipated difficult intubation has been reported, [78] but some find the technique difficult. It
has been used successfully for passage of double-lumen tubes and in patients in whom use of the FFL
proved difficult. In a patient with cervical spine injury, an OS may be better than the Macintosh but not as
good as an RIL. [76] OSs have been used successfully in awake patients.

Tracheal Intubation through the Laryngeal Mask Airway

The LMAc has been used to facilitate tracheal intubation in both elective and rescue situations. Blind
techniques have a low success rate and a significant risk of causing airway trauma. However, passage of a
tracheal tube mounted on an FFL through the LMA can achieve a high tracheal intubation success rate with
minimal risk of trauma, [79] but the widest tracheal tube that will pass down a size 3 or 4 LMA is 6 mm (ID).
The tracheal tube must also be long enough for the cuff to lie 2 cm beyond the vocal cords when the proximal
end is level with the LMA connector. A 6-mm (ID) microlaryngeal tube is particularly satisfactory because it is
sufficiently long and the cuff diameter is suitable for adult patients. However positive-pressure ventilation
during fiberoptic intubation through a size 3 or 4 LMA with a 6-mm tracheal tube is unsatisfactory because of
the restricted air channel between the tube and the LMA. [80] Techniques for subsequent LMA removal have
been described, but they may fail and expose the patient to the danger of accidental extubation. The AIC
( Fig. 50-15 ) is used in a two-stage fiberoptic technique that facilitates insertion of a wider tracheal tube and
safe removal of the LMA. [72] This hollow guide is 56 cm long and fits snugly over a standard (narrower is
recommended) FFL, apart from its controllable tip. The AIC is mounted on the FFL, and the combined unit is
steered under vision through the LMA and into the trachea. When the tip of the AIC reaches the lower portion
of the trachea, the LMA and FFL are withdrawn and a tracheal tube (7 mm or larger) is then passed over the
AIC. The technique is mastered rapidly. The AIC has been used successfully with other SADs.


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Figure 50-15 Aintree intubating catheter within a flexible fiberoptic laryngoscope, inserted through a laryngeal mask airway and
advanced into the trachea.

Intubating Laryngeal Mask Airway

The ILMA (Fastrach) was designed as a conduit for tracheal intubation to facilitate ventilation between
attempts at tracheal intubation. [71] The rigid handle and airway tube enable rapid and precise control of mask
position. The 13-mm ID allows passage of a tracheal tube as wide as 8 mm (ID). An epiglottic elevating bar is
designed to elevate the epiglottis as the tube is advanced into the bowl. Single- and the original multiple-use
versions of the ILMA are available. Dedicated reusable or single-use tracheal tubes are designed to facilitate
atraumatic blind intubation through the ILMA. The tubes are straight, reinforced with wire, and have a soft
molded tip with the leading edge close to the midline. The reusable tube has a low-volume, high-pressure
cuff, whereas the single-use tube has a high-volume, low-pressure cuff. Standard polyvinyl chloride tracheal
tubes should not be used for blind intubation through the ILMA because they exert much higher tissue
pressure as they exit from the ILMA and repeated attempts at passage may cause serious damage to the


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The technique of insertion of the ILMA differs in many respects from insertion of the LMAc, and there is a
significant learning curve. A neutral head position (nonextended head on a support) is recommended. The
ILMA handle is used to rotate the mask into the pharynx. Oxygenation, ventilation, and anesthesia are
stabilized after insertion. If resistance to ventilation is encountered, the position of the ILMA is adjusted. The
up-down maneuver is recommended for management of a down-folded epiglottis, but prior jaw thrust may
be needed. The Chandy maneuver consists of two separate maneuvers: The ILMA is rotated in the sagittal
plane until resistance to bag ventilation is minimal. The ILMA is then lifted gently from the posterior
pharyngeal wall just before passage of the tracheal tube. The value of the Chandy maneuver is disputed.
Passage of the tracheal tube should be performed gently. The ILMA should be removed soon after tracheal
intubation has been verified because its rigidity results in high pressure on adjacent tissues.
A high success rate can be achieved. However, the technique of tracheal tube passage is blind, several
attempts may be required, and esophageal intubation can occur. Laryngeal and esophageal damage has
been reported. The risk of failure is increased in the presence of laryngeal lesions and previous cervical
radiotherapy. Intubation under vision with the FFL through the ILMA achieves higher first-attempt and overall
success rates than blind techniques do.
The ILMA is the SAD of choice for blind tracheal intubation and is of proven value as a rescue device in
cases of unanticipated difficult intubation. However visualization of the larynx through the ILMA is not as good
as that achieved with the LMAc. [81] Use of the ILMA may be difficult if mouth opening is restricted or the
glottis is displaced. Use of the ILMA in an awake patient when difficulty with tracheal intubation is
anticipated has been reported. Awake intubation through the ILMA has few advantages and some
disadvantages in comparison to awake FFL intubation through a tubular oropharyngeal airway. [69]

The C-Trach is a variation of the ILMA that uses fiberoptic bundles to transmit an image from within the bowl
of the mask and provides illumination through a light bundle. A separate unit that contains a camera, video
display, and source of illumination is attached after insertion of the C-Trach. The display facilitates optimum
positioning of the device, but the view remains poor in some patients. [82] Tracheal intubation under vision has
been achieved with the C-Trach after failed intubation attempts with the FFL or ILMA, [82] including a case of
undiagnosed lingual tonsil hypertrophy. The image is not as good as that produced by a conventional FFL,
[82] with problems including secretions, inadequate light intensity, and obstruction of the view by the
epiglottis. [83] However, the C-Trach is a relatively portable, inexpensive system that can be prepared rapidly
and facilitates ventilation between attempts at passage of the tracheal tube.

Retrograde Intubation
The retrograde technique of intubation consists of percutaneously passing a narrow flexible guide into the
trachea from a site below the vocal cords and advancing this guide through the larynx and out the mouth or
nose. In the basic technique, the tracheal tube is then passed over the guide into the upper part of the
trachea, the guide is removed, and the tube is advanced into the trachea ( Fig. 50-16 ). Guides may emerge
from the mouth or nose. If nasal intubation is planned and the guide comes out of the mouth, a soft catheter
can be passed through the nose, retrieved from the mouth, and then used to bring the guide out through the
nose. Guides used have included plastic introducers, epidural catheters, steel guidewires, and sutures.
These guide materials have different properties, but their clinical efficacy has not been compared. Passage of
an epidural catheter through the larynx has been successful after failure with a guidewire, and it is easier to
retrieve a plastic guide than a steel guidewire from the mouth. Guidewires are a better choice for use with the
FFL. The technique can be performed under topical anesthesia in a sedated patient.


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Figure 50-16 Retrograde intubation with the Cook Retrograde Intubation Set. A, After placement of an 18-gauge sheath needle
into the larynx, the J end of the guidewire is inserted in a cephalad direction until it exits the mouth or nose. B, An 11.0 Fr Teflon
catheter is threaded down over the guidewire until it contacts the laryngeal access site. The guidewire is removed from above. C,
After advancing the Teflon catheter 2 to 3 cm, the endotracheal tube is advanced into the trachea while maintaining constant
control of the catheter. (Courtesy of Cook Critical Care, Bloomington, IN.)

Details of the technique are important. Neck extension facilitates access to the cricothyroid membrane. The
guides are inserted through a needle or cannula that is inserted horizontally (so that the vocal cords are not
damaged) with the bevel directed cephalad. The intratracheal position of the initial needle should be
confirmed by aspiration of air. Jaw thrust and tongue traction can facilitate passage of the guide behind the
A number of problems with the retrograde technique have been reported and variations have been developed
( Fig. 50-17 ) to improve reliability. The most frequent problem is that the tracheal tube springs into the
esophagus after the guide is removed, which is a consequence of the location of the cricothyroid membrane
( Fig. 50-18 ) only 1 cm below the vocal cords. Passage of a wider, stiffer plastic sheath over the guide to act


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as an introducer for the tracheal tube improves reliability. Excessive tension on the guide may pull the
tracheal tube anteriorly, thereby causing misalignment and increasing the risk that the tube will be impeded
by the epiglottis or other laryngeal structures. Retrograde intubation through the nose has succeeded when
the oral route failed, probably because impingement on the anterior glottis is less likely. Use of the subcricoid
(cricotracheal) instead of the cricothyroid space may improve reliability at the possible cost of a greater risk of
bleeding. The guide may be threaded through the Murphy eye and then passed up through the proximal
lumen of the tracheal tube. Pulling the tube after tying a knot inside the Murphy eye has succeeded when
other techniques have failed. [84]

Figure 50-17 Variations on the retrograde technique. The cricothyroid membrane is indicated with an arrow. The guide has been
inserted through the cricotracheal space, passed in a loop through the Murphy eye of the tracheal tube, and used to pull it toward
the cricotracheal membrane. A hollow catheter has been passed through the tracheal tube for passage into the trachea to act as
an introducer. These variations may not be used simultaneously in clinical practice.


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Figure 50-18 Anatomy of the cricothyroid membrane. (Courtesy of Cook Critical Care, Bloomington, IN.)

The retrograde technique has some disadvantages. It is invasive and advancement of the tracheal tube is
blind. It involves several steps and can take some time. The most frequent complications are minor bleeding,
subcutaneous emphysema, pneumomediastinum, and infection. Contraindications include coagulopathy,
inability to identify landmarks, laryngeal disease, and local infection. Some have achieved high success rates
with the retrograde technique, [84] but others have recorded low success and significant complication rates.

The great merit of the technique is its simplicity. It has little place in elective practice in advanced hospitals. It
may be the technique of choice when the patient has pharyngeal bleeding and intubation is anticipated to be
impossible. It is useful when awake intubation is indicated but sophisticated equipment is not available.

Lighted Stylet (Light-Guided Intubation)

The term lighted stylet may be used to describe any device that uses a bright light within the tip of a tracheal
tube as a guide to facilitate tracheal intubation. [86] The technique depends on interpretation of the light


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transmitted through the skin of the neck to indicate the position of the tip of the tracheal tube. When the tip is
at the larynx, the light should be in the midline, and its position in the longitudinal plane indicates its position
in relation to the laryngeal cartilage. As the light passes more distally, a localized glow indicates a tracheal
position and a diffuse glow indicates an esophageal position.
There is a significant learning curve, but high success rates with few complications can be achieved by those
who use the technique regularly in routine practice. [87] It can be used with oral or nasal intubation, with
double-lumen tubes, or in conjunction with other devices such as the LMA or ILMA. Successful use in many
difficult airway conditions has been described, [87] including cervical spine disorders and intubation in the
lateral position. Good success rates achieved after the use of NMBDs could not be repeated in nonparalyzed
patients, in whom the incidence of adverse effects was not considered acceptable. [88] Causes of failure
include poor illumination as a consequence of obesity [88] or skin pigmentation, resistance to advancement of
the tracheal tube, and events such as coughing, hypoxemia, and esophageal intubation. [88] The technique is
particularly difficult in the presence of cricoid pressure. It is a blind technique that can damage the larynx.
Contraindications include airway tumors, infection, trauma, and foreign bodies.

Physiologic Response to Tracheal Intubation

Direct laryngoscopy and passage of a tracheal tube are noxious stimuli that can provoke adverse responses
in the cardiovascular, respiratory, and other physiologic systems.
Significant hypertension and tachycardia are associated with tracheal intubation under light anesthesia. The
magnitude of the response is greater with increasing force and duration [10] of laryngoscopy. The elevation in
arterial pressure typically starts within 5 seconds of laryngoscopy, peaks in 1 to 2 minutes, and returns to
control levels within 5 minutes. Such hemodynamic changes can result in myocardial ischemia but seem to
cause little harm to most patients. However they are undesirable in patients with cardiac disease.
It is possible to separate the factors that contribute to the hemodynamic response. Hemodynamic changes
start within seconds of direct laryngoscopy, and there is a further increase in heart rate and blood pressure
with passage of the tracheal tube. Tracheal intubation through the ILMA causes a hemodynamic effect similar
to that caused by direct laryngoscopy. [89] When orotracheal intubation or NTI is performed with the FFL
under general anesthesia without topical anesthesia of the airway, hemodynamic changes are similar to
those seen with the direct laryngoscope.
Many techniques have been tried in an effort to attenuate adverse hemodynamic responses to intubation, but
none is ideal. Prevention by use of an increased depth of anesthesia is attractive in theory. However,
changes in the concentration of anesthetic agents in blood and at effector sites occur slowly in relation to the
onset and offset of airway stimuli and hemodynamic responses. Use of N2O with a volatile agent may be
beneficial. Large doses of narcotics (other than morphine), such as fentanyl, 6 g/kg, suppress the
hemodynamic response but risk prolonged respiratory depression. Aerosol or other application of topical
anesthetics may be beneficial with a low risk of adverse effects. Application of such topical anesthesia may
cause minor adverse hemodynamic effects, much less [90] than those caused by tracheal intubation.
Combinations of topical anesthetics with other drugs such as opioids may be useful.
Drugs that act primarily on the cardiovascular system have been studied. Many can reduce either the blood
pressure or the heart rate response, but not both, and can cause hypotension or bradycardia. Labetalol and
esmolol have been recommended, particularly in combination with narcotics. Use of such drugs is rarely
indicated, however.
Another approach to reducing the cardiovascular response to tracheal intubation is to modify the technique of
tracheal intubation. Awake flexible fiberoptic intubation with effective topical anesthesia almost eliminates the
hemodynamic response to tracheal intubation.
Direct arterial pressure monitoring throughout induction of anesthesia is desirable in a high-risk patient so
that the anesthesiologist can respond to accurate, continuous hemodynamic information. Moderate
depression of arterial pressure and heart rate before laryngoscopy might limit the rise in arterial pressure at
the expense of initial cardiorespiratory depression. Prolonged attempts at laryngoscopy should be avoided.
Careful cardiovascular monitoring and willingness to interrupt direct laryngoscopy while anesthesia is


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deepened are keys to maintenance of reasonable homeostasis.

Respiratory System
Protection of the lungs from pulmonary aspiration is a core function of the upper airway. Laryngospasm is
discussed elsewhere. It must be treated vigorously. Bronchospasm accounted for 2% of claims in the ASA
Closed Claims Study, half in patients without a previous history of asthma. [64] An increase in airway
resistance frequently occurs after tracheal intubation and can be reduced by prophylactic bronchodilator
therapy. In patients with asthma, prophylactic steroids and bronchodilators [91] reduce the bronchoconstriction
associated with tracheal intubation, as does topical lidocaine with flexible fiberoptic intubation. [92]

Confirmation of Tracheal Intubation

Misplacement of the tracheal tube in the esophagus or right main bronchus is still a major cause of avoidable
anesthetic morbidity and mortality. [43] Immediate confirmation of correct tracheal tube placement is an
essential and integral part of tracheal intubation. Several tests should be used because no single test is
completely reliable. [93] The most important safeguard is clinical suspicion. Visual confirmation of passage of
the tracheal tube between the vocal cords is reliable, but not always possible, and experienced
anesthesiologists are occasionally misled. The esophageal detector (negative-pressure) test is simple and
inexpensive and may be performed before initial ventilation. Air can readily be aspirated from the trachea, but
attempted aspiration from the esophagus causes apposition of its walls around the tube so that aspiration of
air is not possible. A syringe or self-inflating bulb may be used. It is particularly valuable in cardiac arrest and
other emergency intubation situations, but misleading results occur, particularly after gastric insufflation and
in the presence of pulmonary disease, obesity, and pregnancy. Airway obstruction has been caused by
aspiration of mucus into the tracheal tube. It should be regarded as a device to augment other techniques,
particularly when capnography is not available.
A gurgling sound with the first inflation suggests esophageal intubation. Auscultation over the epigastrium
and axillae is usually reliable, but there are many sources of error [93] and other confirmation must be sought.
Identification of CO2 in the expired gas is the standard for verification of proper tracheal tube placement, and
a characteristic waveform over several breaths is sought. However, there are many possible causes of falsenegative and false-positive results. [93] Carbon dioxide concentrations are low or zero despite tracheal
intubation in very low cardiac output states, severe respiratory disease, and capnograph or other equipment
malfunction. A CO2 waveform may be detected from the esophagus after gastric insufflation during facemask
ventilation or ingestion of carbonated beverages, but these CO2 concentrations decline rapidly with
successive breaths. A glottic or pharyngeal position of the tracheal tube tip can give a normal capnograph
and acceptable breath sounds but leave the patient exposed to the risk of accidental extubation and
inadequate airway protection. Colorimetric devices sensitive to low concentrations of CO2 may be
misinterpreted as tracheal intubation when the tube is in the esophagus. Identification of the tracheal rings
and carina through a standard or simplified [94] FFL passed down the tracheal tube provides reliable
confirmation of proper position.
Early hypoxemia after tracheal intubation should be regarded as esophageal intubation until proved
otherwise. If there is any suspicion of esophageal intubation, the traditional maxim is if in doubt, take it out,
but this strategy is not without risk in that a correctly placed tube may be removed from a hypoxemic patient.
Accidental bronchial intubation can occur during intubation or subsequently, especially if head flexion is
increased after initial tracheal tube fixation, the diaphragm is elevated by increased intra-abdominal pressure,
or a head-down position is used. It can cause serious morbidity. The most important sign is hypoxemia,
usually combined with increased airway pressure. Bronchial intubation is suggested by asymmetric chest
expansion. Auscultation over both axillae is usually, but not always diagnostic. Absence of breath sounds
over one lung, generally the left, strongly suggests bronchial intubation, but pneumothorax and any causes of
atelectasis can also produce this picture. The diagnosis can still be difficult in patients with lung disease, and
use of the standard or simplified [95] FFL or chest radiography may be necessary.
Unplanned tracheal extubation is a significant cause of morbidity and mortality. The risk is high in patients
with facial burns, in whom the tracheal tube should be left long to allow for facial swelling. The tracheal tube
is secured after confirmation of satisfactory position so that it will neither come out nor advance into the right


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main bronchus. Adhesive or tie tape, or both, may be used. Venous congestion caused by tape tied around
the neck should be prevented. Proprietary devices are available, and sutures have also been used.

Care During Surgery

When the airway has been secured, any immediate complications of intubation should be treated. TMJ
function should be checked immediately after any procedure that involves maximum mouth opening to
prevent undiagnosed dislocation.
Careful intraoperative monitoring of the airway is essential because problems during surgery are a cause of
morbidity and mortality. [43] Intraoperative tracheal tube obstruction can be caused by biting, kinking, external
compression, and secretions or other intraluminal material. The clinical picture of increased airway pressure
and hypoxemia may also be caused by bronchospasm, pneumothorax, surgical manipulation, lung collapse,
and raised intra-abdominal pressure. Resistance to passage of a gastric tube or suction catheter down the
tracheal tube indicates obstruction but not the cause. Examination with the FFL may be needed to make a
complete diagnosis.
Leaks in the anesthesia circuit may be caused by disconnection of the circuit, cuff leaks, or supraglottic
position of the tube. Disconnection of anesthesia circuit components should be detected rapidly with the
capnograph and respiratory volume monitoring. Leakage of air when the tracheal tube cuff is intact may be
caused by insufficient depth of insertion of the tracheal tube so that the cuff lies between or proximal to the
vocal cords. Cuff pressure is likely to be elevated, and the tube markings will indicate insufficient depth of
insertion. The diagnosis can be confirmed by chest radiography or fiberoptic endoscopy. Low-pressure leaks
may be due to damage to the cuff, inflation tube, or valve. Valve incompetence can often be managed by
insertion of a three-way stopcock. If major leakage from the cuff cannot be managed by cuff inflation, the
tracheal tube will need to be changed (preferably over an introducer or airway exchange catheter [AEC]) to
prevent hypoventilation or pulmonary aspiration. If intraoperative tube replacement is judged too dangerous,
pharyngeal packing may reduce the leak, but airway protection is limited and there is a risk of gastric
insufflation. Inadvertent insertion of a nasogastric tube into the trachea is a rare cause of leakage.

The tracheal tube (extubation) is removed when it is no longer needed for airway protection. Timing and
technique are influenced by the balance between the residual effect of anesthetic drugs and recovery of
airway and other reflexes. A significant number of complications ( Box 50-13 ), including death, occur around
the time of extubation. [43] The ASA recommends that the anesthesiologist have a preformulated strategy for
extubation and management of postextubation problems. [6] Essential components of the strategy include
continued administration of oxygen, continued ventilation, and a strategy to facilitate reintubation.
Box 50-13

Complications at Extubation

Hypoventilation (residual effect of anesthetic drugs and neuromuscular blockade)

Upper airway obstruction
Laryngospasm and bronchospasm
Coughing (wound disruption)
Impaired laryngeal competence and pulmonary aspiration
Hypertension, tachycardia, dysrhythmias, myocardial ischemia
Extubation may be performed at different depths of anesthesia, with the terms awake, light, and deep
often being used. Light implies recovery of protective respiratory reflexes and deep implies their absence.
Awake implies appropriate response to verbal stimuli. Deep extubation is performed to avoid adverse


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reflexes caused by the presence of the tracheal tube and its removal, at the price of a higher risk of
hypoventilation and upper airway obstruction. Straining, which could disrupt the surgical repair, is less likely
with deep extubation. Upper airway obstruction and hypoventilation are less likely during light extubation,
at the price of adverse hemodynamic and respiratory reflexes. An alternative strategy of replacing a tracheal
tube with an LMA during deep anesthesia has been described. However, there are risks of hypoventilation
and malposition of the LMA.
Pathophysiology and Pharmacology of Extubation

Restart of respiration after positive-pressure ventilation can be erratic, with apnea occurring in the presence
of hypercapnia. Respiratory complications at extubation include pulmonary aspiration, upper airway
obstruction, or hypoventilation leading to hypoxemia and laryngospasm. Laryngeal function is impaired, even
after use of an LMA, [42] and may be particularly severe after neck and thyroid surgery. The risk of impaired
laryngeal function is increased in patients with neurologic or neuromuscular disease. Coughing may be
particularly troublesome during light anesthesia extubation and cannot be entirely prevented. The frequency
of cough may be reduced when the volatile used is sevoflurane. Intravenous alfentanil and lidocaine can also
reduce the risk of coughing, as can local anesthetic in the tracheal tube cuff or applied to the airway.
Cardiovascular complications include arterial hypertension (with an associated increase in intracranial and
ocular pressure), tachycardia, and dysrhythmias. Pulmonary edema may be caused by myocardial ischemia
or by negative intrapulmonary pressure created by respiratory effort during airway obstruction. Marked
increases in arterial blood pressure and heart rate occur frequently at the time of light extubation. These
effects are alarming but normally transient, and there is little evidence of adverse consequences. However,
they may cause detrimental increases in intracranial and intraocular pressure after neurologic and ophthalmic
surgery. Many techniques can reduce the incidence of these adverse effects. Narcotics, -adrenergic drugs,
and calcium channel blocking drugs have been studied most extensively. The results are conflicting and there
is a risk of adverse effects. On the rare occasions when these drugs are indicated, short-acting agents should
be used and direct arterial pressure monitoring continued.
Rapid recovery of consciousness shortens the at-risk time during extubation and may reduce morbidity,
particularly in obese patients. Avoidance of sedative premedication facilitates rapid recovery. Nitrous oxide,
sevoflurane, and desflurane all contribute to rapid recovery, particularly after prolonged procedures.
Remifentanil also facilitates rapid recovery, early extubation, and high SpO2 values on admission to the
postanesthesia care unit.

The sniff position is the standard position for extubation. Its major advantage is that airway management,
including reintubation, is optimized. The recovery (lateral) position may be a safer option when there is an
increased risk for pulmonary aspiration. Gravity causes soft tissues and any foreign material in the pharynx to
move downward and away from the larynx and fluid to drain out of the mouth, so the risk of upper airway
obstruction and pulmonary aspiration is reduced. Preemptive turning of at-risk patients into the recovery
position is wise because emergency turning of a vomiting or regurgitating patient creates increased risk for
the patient and staff. The combination of the recovery position with awake extubation is recommended for
patients at high risk for pulmonary aspiration. If the recovery position cannot be used in such patients, awake
extubation is mandatory. Use of the recovery position with minimal stimulation reduces the incidence of
laryngospasm, coughing, and desaturation. [96]
Extubation after Uncomplicated Airway Management

Preparations for extubation are shown in Box 50-14 . Recovery of neuromuscular function is essential, but
confirmation can be difficult. Respiration should be well established and confirmed by capnography and
measurement of ventilation. Preoxygenation before extubation delays the onset of hypoxemia if upper
airway obstruction develops and is recommended. Throat packs must be removed before extubation.
Complete airway obstruction caused by biting a tracheal tube as anesthesia lightens can lead to the rapid
development of hypoxemia and may be followed by negative-pressure pulmonary edema. Bite blocks reduce
but do not eliminate the risk of tracheal tube compression. Insertion of a bite block, if not in place, should be
considered as the anesthesia lightens.


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Box 50-14

Preparation for Extubation

Initial Plan
Deep extubation
Awake extubation
Deep replacement of the tracheal tube with a laryngeal mask airway
Other Preparations
Patient position plan
Bite block in place
Throat pack removed
Secretions aspirated from the pharynx (the trachea also if indicated)
Suction of pharyngeal secretions or other material before extubation should reduce the risk of pulmonary
aspiration or laryngospasm. Positive-pressure extubation may expel secretions lying above the cuff but
should be performed carefully to prevent complications caused by raised airway pressure.
Inability to deflate the cuff may be due to occlusion of the pilot tube. Surgical fixation by sutures or other
devices may cause resistance to withdrawal of the tube. Force should not be used. Fiberoptic examination
may confirm the diagnosis, and surgical re-exploration may be necessary.
Laryngospasm at Extubation

Management of laryngospasm at extubation differs from intraoperative management of laryngospasm in that

use of intravenous anesthetics will delay recovery. The Larson maneuver, pressure on the laryngospasm
notch (between the angle of the mandible and the mastoid process), is noninvasive, safe, and often
effective. [30] It is also a useful stimulant whenever there is respiratory depression after extubation. Helium is
of proven value in the management of postextubation stridor. It does not resolve the underlying process but
can increase tidal volume, improve oxygenation, and reduce anxiety. The ratio of oxygen to helium should be
adjusted according to the clinical response. [97] If hypoxemia is severe or the laryngospasm does not respond
to these noninvasive measures, succinylcholine should be given and the patient reintubated. The best help
available should be sought whenever reintubation is performed in suboptimal conditions.
Extubation of Patients with a Difficult Airway

Many surgical and anesthetic factors (including airway disease, surgery, and trauma; cervical spine and other
head and neck surgery; and difficult tracheal intubation, especially multiple intubation attempts) can cause
swelling of tissues in the upper airway and increase the risk for airway obstruction after extubation. Other risk
factors include obesity and a history of obstructive sleep apnea. [43] Such patients have died at extubation as
a consequence of airway obstruction and failure to reintubate. [98] Important management issues for
extubation of these patients include airway risk assessment and location, time, and technique of extubation.
The principal extubation risk assessments tests are the leak test and visual inspection and imaging of airway
swelling. Leak tests are used to determine whether gas can pass between the tracheal tube and wall of the
trachea after cuff deflation. The hypothesis is that this information indicates the absence of swelling and
predicts airway patency after removal of the tracheal tube. Leak tests have been performed in different ways.
There is a risk that negative-pressure pulmonary edema will develop when the leak test is performed during
spontaneous ventilation. Results are conflicting, and a leak does not guarantee airway patency after


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extubation. However, low leak volumes are associated with an increased risk for upper airway obstruction. [99]
Whenever there is any doubt about risks, a flexible fiberoptic endoscope should be used to assess swelling
and other causes of upper airway obstruction.
An extubation-risk patient should remain intubated in the intensive therapy unit until there is evidence that
airway swelling has resolved. Other factors such as altered neurologic status may affect the time of
extubation, and tracheotomy may be needed in such patients. Extubation should not be performed when
there is an increased risk for vomiting or regurgitation. The intensive therapy unit and the operating room are
the safest places for extubation. A full range of equipment and personnel should be available, and all
preparations, including surgical, should be made for airway management. Extubation should be performed in
an awake patient after breathing 100% oxygen to maximize oxygen stores. Helium, noninvasive ventilation,
and CPAP may reduce the need for reintubation.
Airway Exchange Catheters

Solid introducers have been used as guides for reintubation. They are passed through the tracheal tube
before extubation and kept in situ until the possible need for reintubation has passed. AECs have been
introduced as hollow reintubation guides that have the additional potential capability of maintaining
oxygenation or monitoring tracheal gas. They are normally supplied with 15-mm and Luer connectors. The
ideal depth of insertion of the tip of the AEC is midtracheal. AECs are generally well tolerated by awake
patients, who can breath around them. Insufflation of oxygen at low pressure or positive-pressure ventilation
by the intermittent application of high pressure is possible. If positive-pressure ventilation is used, it should be
started with great caution. The lowest pressure that produces an acceptable tidal volume, judged by
movement of the chest and upper part of the abdomen, should be used. The next inspiration should not start
until the chest returns to its preinspiration position. Expiratory resistance should be minimized by jaw thrust
and head extension, augmented by an oropharyngeal airway or LMA, if required. The concern about
oxygenation through AECs is the significant risk for barotrauma. [100] Although insufflation through AECs
without barotrauma has been reported, insufflation through the FFL and AEC has caused serious
barotrauma. Insufflation through an AEC is of doubtful value when oxygen can be administered by facemask.
[101] The need for AEC ventilation should be weighed against the risks. It should be considered only by users
who have practiced the AEC technique in workshops.

Percutaneous Airway
A percutaneous (transcutaneous) airway connects the trachea and lower airway to the atmosphere,
anesthesia circuit, or other device through a surgically created opening in the front of the neck that bypasses
the larynx and upper airway. Rapid emergency creation of such an airway is necessary when noninvasive
techniques fail to relieve the cannot intubate, cannot ventilate situation and severe increasing hypoxemia
develops. Creation of a percutaneous airway involves significant hazards.

Tracheotomy requires incision of the skin and subcutaneous tissues, separation of the strap muscles, division
of the isthmus of the thyroid gland, incision of the anterior wall of the trachea, and insertion of a cuffed
tracheotomy tube. Access is improved by neck extension achieved by placing a bolster under the shoulders.
Emergency tracheotomy can be very difficult and give rise serious complications. [102] A few surgeons may
succeed in 3 minutes, but most take longer. Delay in completion of tracheostomy in this situation is likely to
result in death of the patient. Elective tracheotomy for airway management is indicated when the risk of loss
of the airway during attempted tracheal intubation is high, such as when respiration is compromised by
laryngeal tumors or deep neck abscesses. Wherever possible, tracheotomy is performed in a patient who is
already intubated because operating conditions are better for the surgeon. The anesthesiologist coordinates
withdrawal of the tracheal tube with the surgical incision in the trachea. Sensible precautions include
preoxygenation before incision of the trachea and insertion of an introducer or AEC as the tracheal tube is
withdrawn so that reintubation is facilitated, if necessary. Tracheotomy is performed under local anesthesia in
an awake patient if the risk of airway loss during tracheal intubation is high.
Tracheotomy is also used as a replacement for orotracheal intubation in a critically ill patient who requires
prolonged airway support. Dilatational tracheotomy is used frequently. Discussion of the technique is beyond


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the scope of this chapter.

Cricothyrotomy creates a percutaneous airway through the cricothyroid membrane. Its advantages over
tracheotomy are that the membrane is superficial and relatively avascular and cartilage incision is not
necessary because the height of the membrane is greater than the distance between the tracheal rings.
Cricothyrotomy can be performed with a surgical or cannula (needle) technique, and appropriate use can
prevent anesthetic-related deaths. It is a core skill for the anesthesiologist.
Surgical Cricothyrotomy

Surgical cricothyrotomy uses surgical techniques to insert a cuffed tube in the trachea (successful lowpressure ventilation with an uncuffed tube is not guaranteed [103] ). It facilitates rapid restoration of ventilation
and oxygenation in the cannot intubate, cannot ventilate situation. [2] Emergency cricothyrotomy can cause
serious complications, [102] although they are infrequent when staff is well trained. [104] The four-step simplified
cricothyrotomy technique ( Box 50-15 ) can be performed in 30 seconds. [105] A No. 20 scalpel is preferred
because its width is sufficient for insertion of a narrow tube without the need for extension of the incision, and
its length is such that damage to the posterior wall of the trachea is unlikely. In an obese patient in whom the
laryngeal cartilage cannot be identified, step 1 is modified to include an initial vertical incision so that the
cartilage can be identified. Insertion of the tube in an obese patient may be facilitated by passage of an
introducer into the trachea. When oxygenation has been restored, hemostasis can be secured.
Box 50-15

Surgical Cricothyrotomy
No. 20 scalpel
Cuffed tracheal or tracheostomy tube with a 6- or 7-mm internal diameter
Step 1: Extend the head and neck and identify and immobilize the cricothyroid membrane (initial
vertical incision if identification is not possible)
Step 2: Horizontal stab incision through the skin and cricothyroid membrane. Leave the blade in
place until the tracheal hook is in position (step 3)
Step 3: Caudal and outward traction on the cricoid cartilage with the tracheal hook; remove the
Step 4: Insert the tube and inflate the cuff
Step 5: Ventilate with a low-pressure source
Step 6: Confirm pulmonary ventilation
Seldinger Cricothyrotomy

Anesthesiologists are reluctant to perform emergency surgical techniques, and thus Seldinger guidewire
cricothyrotomy techniques have been developed. [103] These techniques are preferred by many
anesthesiologists because they do not involve unfamiliar surgical techniques. Seldinger cricothyrotomy has
taken longer than the surgical technique to restore the airway in most studies. Kinking of the guidewire can
be a serious problem.
Cannula (Needle) Cricothyrotomy

Cannula cricothyrotomy requires the combination of a cannula through the cricothyroid membrane with high-


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pressure ventilation. It can provide effective ventilation, [46] although low success rates have been reported.
Kink-resistant cannulas must be used because standard intravenous cannulas are easily kinked. The
technique is summarized in Box 50-16 and described in detail elsewhere. Verification of correct cannula
placement by aspiration of air into a large syringe before the use of high-pressure ventilation is essential.
Subsequent dislodgement of the cannula must be prevented.
Box 50-16

Cannula Cricothyrotomy
Kink-resistant cannula
High-pressure ventilation system
Insert the cannula through the cricothyroid membrane
Confirm tracheal position by aspiration of air with a 20-mL syringe
Maintain position of the cannula with a dedicated hand
Attach the ventilation system to the cannula
Ensure an open upper airway (including jaw thrust, head extension, and possibly a laryngeal
mask airway)
Commence cautious ventilation
Confirm inflation and deflation of the lungs and exhalation through the upper airway
Convert to a surgical cricothyroidotomy if ventilation fails or any complications develop
Effective ventilation through a cannula is possible only when a high-pressure (e.g., hospital pipeline) source
is used, and an adjustable device with a Luer-Lok connection is recommended. Barotrauma is a serious
complication. It is less likely if an initial inflation pressure of less than 4 kPa (55 psi) is used. Ventilation
should be started cautiously. It is important to keep the upper airway as open as possible and to verify
deflation of the lungs and exhalation through the upper airway. Cannula cricothyrotomy can be safe only if
meticulous technique is practiced regularly and safety rules are observed. Elective cannula cricothyrotomy
may have a role in ENT surgery and when a difficult airway is anticipated. [106]

Complications of Airway Management

Many complications are associated with airway management and some are considered elsewhere in this
chapter. The most serious complications are hypoxemia and soft tissue damage to the pharynx and
esophagus. Hypoxemia should be preventable when anesthesiologists avoid high-risk strategies and have a
sufficient range of skills to manage a wide variety of scenarios. Soft tissue damage is responsible for 6% of
closed claims. [65] Mediastinitis should be prevented by gentleness and avoiding repeated use of techniques,
particularly blind ones, when they prove ineffective. Unfamiliar techniques should not be used for the first time
in an emergency situation. The effects of any trauma should be mitigated by arranging good follow-up care.
[65] Damage to the glossopharyngeal, hypoglossal, lingual, superior laryngeal, recurrent laryngeal, mental,
and branches of the trigeminal nerve has been reported after airway management. This damage has been
attributed to direct trauma or cuff pressure.
Less serious complications occur more frequently. Dental damage is the most frequent cause of complaints
against anesthesiologists, [12] with an incidence of 1 in 4500 reported from one department. [58] Serious
injuries include subluxation, fracture, and avulsion of teeth. [58] Diseased teeth are at particularly high risk, but
healthy teeth can also be injured. Only the most serious injuries are likely to lead to complaint, so the
incidence of minor dental injury is probably higher than realized. Use of dental guards during direct


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laryngoscopy has been advocated, but prevention of injury is not guaranteed, the efficacy of direct
laryngoscopy may be reduced, and the risk of injury may be increased. Injury to healthy teeth in patients
undergoing elective surgery should be prevented by using alternative airway techniques if pressure on teeth
cannot be avoided with the first laryngoscopy technique chosen. Dental damage can also be caused by
insertion and removal of or biting on several airway devices. An urgent dental consultation should be
arranged after any dental damage. Any dislodged teeth or fragments should be located and, if in the
respiratory tract, removed.
Laryngeal damage has been found in 84% of patients, 69% of whom were symptomatic, when computed
tomography was performed 6 months or longer after tracheal intubation for elective surgery. Patients with
hoarseness or other signs of laryngeal damage after airway management should be referred to an ENT
surgeon. Laryngeal and tracheal damage after long-term intubation is beyond the scope of this chapter.
Although the number of claims for airway management complications remains substantial, results from single
hospitals show that airway management can be accomplished with a very low incidence of serious
complications. [10] [46] [47] [63]

Follow-up After Difficulty with Airway Management

The anesthesiologist has continuing responsibility for issues that may influence future safety of the patient.
The ASA guidelines [6] recommend that the anesthesiologist document the presence and nature of any
airway difficulty, inform the patient, and evaluate and arrange appropriate management of complications.
Documentation is summarized in the ASA guidelines and should include a description of the airway
difficulties, the management used, and the number and duration of attempts. [6] Possible notification systems
include a written report or letter to the patient, a written report in the medical chart, and communication with
the patient's surgeon or primary caregiver. Because only a warning bracelet (e.g.,
may be effective if the patient is admitted unconscious to hospital, additional use of this system is
Patients in whom laryngoscopy proves unexpectedly difficult are entitled to a diagnosis and appropriate
management. Fiberoptic nasendoscopy [3] [6] and appropriate imaging should be considered. Domino and
coworkers stated that patients in whom tracheal intubation has been difficult should be observed for and told
to watch for the development of symptoms and signs of retropharyngeal abscess, mediastinitis, or both. [65]
Death is less likely if the diagnosis is made and treatment started promptly.

Cleaning and Disinfection of Airway Equipment

Equipment used for invasive procedures, including airway management, should be sterile to prevent crossinfection. The risk of spreading prion disease with the use of contaminated medical equipment [107] is a
particular problem because conventional cleaning and sterilization do not remove protein deposits from
equipment. Furthermore, sterilization can cause deterioration in equipment performance, such as the effect of
repeated autoclaving on the fiberoptic bundles of direct laryngoscopes.
Transfer of infected material can be prevented by using single-use equipment. However, single-use
equipment (direct laryngoscopes, introducers, SADs) has frequently been introduced without evidence of
efficacy. In the case of direct laryngoscopes, there has been great variation in rigidity in the longitudinal and
torsional axes. The blades are often thicker and thus the view of the larynx is impaired, and there is less room
for maneuvering the tracheal tube. The illumination provided by single-use blades varies in intensity, width of
the beam, and direction. Plastic single-use blades perform less well than standard metal reusable blades,
may result in a longer duration of laryngoscopy, and are not recommended for rapid-sequence induction

Challenging Airway Management Scenarios

Risk of Pulmonary Aspiration
Foreign material may be aspirated into the lungs when the normal laryngeal protective mechanisms fail.
Pulmonary aspiration was confirmed in 1 in 8600 anesthetic procedures in a recent review. [108] The clinical


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consequences depend on the quantity, nature, and distribution of the material aspirated; the relative impact of
the acid, bacterial, and particle content; and patient factors. The range of effects varies from cough and
laryngospasm caused by aspiration of a small volume of pharyngeal contents to drowning secondary to
aspiration of liters of gastrointestinal contents. Pulmonary aspiration accounted for 4% of claims in the ASA
Closed Claims Study. [1] Most cases occur during induction of anesthesia or, less frequently, at extubation
and recovery. [108]
When the lower and upper esophageal sphincters are working optimally, they prevent passive regurgitation
from the stomach to the esophagus and from the esophagus to the pharynx, respectively. Their tone is
reduced as consciousness is lost. Tone may be increased or decreased as a secondary effect of a variety of
procedures and drugs used by anesthesiologists.
Major risk factors for regurgitation and vomiting include pregnancy after the first trimester and acute
gastrointestinal disease, particularly esophageal or gastric disease, small bowel obstruction, and ileus. Other
risk factors for gastrointestinal stasis include trauma, diabetes, obesity, and the administration of drugs (such
as narcotics) that inhibit gastrointestinal function. The head-down and lithotomy positions increase the risk for
regurgitation. Parkinson's disease, bulbar palsy, myotonia dystrophica, and other neurologic diseases impair
protective reflexes and increase the risk for pulmonary aspiration. Recent ingestion of food is a risk factor, but
fasting from the midnight before surgery to any time in the following day is thought to be excessive. [109]
Fasting for 6 hours after a light meal and 2 hours after clear fluids is widely accepted as safe practice for
patients without risk factors [109] ; however, regurgitation can occur in patients without risk factors and
anesthesiologists should always be prepared.
Awake tracheal intubation is the technique of choice when there is a risk of pulmonary aspiration and difficulty
with airway management is predicted. Concern that an increased risk for pulmonary aspiration may be
produced by topical anesthesia of the larynx has proved unfounded in a large series of high-risk patients.
Consciousness contributes significantly to airway protection.
RSI is used to reduce the risk of pulmonary aspiration in at-risk patients. The principle of RSI is that tracheal
intubation is achieved as rapidly as possible to reduce the time at risk for pulmonary aspiration and the
development of hypoxemia. Preoxygenation, intravenous anesthesia, rapid-onset neuromuscular blockade,
and use of cricoid pressure (controversy discussed later) are the essential components of RSI.
Cricoid pressure has been used to prevent pulmonary aspiration since its description by Sellick. The
hypothetical basis is that pressure on the front of the cricoid cartilage is transmitted to its posterior lamina,
which occludes the esophagus by compression against the vertebral bodies. Radiology and cadaver studies
have demonstrated occlusion of the esophagus with cricoid pressure. However, lateral displacement of the
esophagus has been found in 91% of patients when cricoid pressure was applied. [110] Many
recommendations about the technique of cricoid pressure have been made. It should be applied in such a
way that it does not interfere with insertion of the laryngoscope. Cricoid pressure may be applied with an
initial force of 10 N (a weight of about 1 kg, which is tolerable) when the patient is awake and then increasing
to 30 N (about 3 kg), which minimizes the risk of airway obstruction, as consciousness is lost. [52] The force
should be reduced, with suction at hand, if it impedes laryngoscopy or passage of the tracheal tube.
Cricoid pressure has disadvantages. It reduces the tone of the lower esophageal sphincter, so the risk of
regurgitation from the stomach to the esophagus is increased. It can impair insertion of the laryngoscope,
degrade the view of the larynx, impede passage of an introducer or tracheal tube, and cause airway
obstruction. [111] Application of cricoid pressure by an assistant impedes external laryngeal manipulation by
the anesthesiologist. Fracture of the cricoid cartilage has been attributed to cricoid pressure. Vomiting in the
presence of cricoid pressure may generate enough pressure to rupture the esophagus, although low levels of
cricoid pressure might be safe in the presence of vomiting.
The role of cricoid pressure has become controversial. [112] The lack of prospective studies has been
criticized, but ethical issues make such studies impossible. Difficult laryngoscopy caused by cricoid pressure
may have caused deaths. Pulmonary aspiration has occurred despite the use of cricoid pressure, possibly
partly as a consequence of iatrogenic difficulty with tracheal intubation. [108] However, occasional
complications do not mean that the technique is of no value. Pulmonary aspiration has occurred when cricoid
pressure was not applied, and case reports of massive regurgitation after release of cricoid pressure provide


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evidence of its value. However, there must be a low threshold for reducing cricoid pressure when there are
problems with mask ventilation, laryngoscopy, or passage of the tracheal tube.
Use of wide-bore gastric tubes to empty the stomach before RSI has been recommended even though
pulmonary aspiration can occur despite the presence of a nasogastric tube. Suction on a nasogastric tube
can reduce the volume of gastric contents, but there is no guarantee that the stomach will be emptied. The
stomach regularly fills from below in patients with intestinal obstruction. The presence of a nasogastric tube
may increase the risk associated with regurgitation, and removal of the tube while suctioning has been
advised before the implementation of RSI. The opposite view is that gastric tubes may limit rises in gastric
pressure. Insertion of a nasogastric tube before induction of anesthesia is rarely indicated except in patients
with gastrointestinal obstruction or ileus. [113]
Drugs (antacids, histamine H2 receptor antagonists, proton pump inhibitors) may be used to reduce the
acidity or volume (or both) of gastric fluid. These drugs should be given on the day of surgery to patients for
whom they are already prescribed. Their use for premedication of patients with symptoms of
gastroesophageal reflux disease is prudent. Neutralization of gastric contents with nonparticulate antacid in
obstetric or other patients at high risk for aspiration of acid is recommended.

Anticipated Difficult Intubation

The basic management decisions for all patients are described in the ASA guidelines (see Fig. 50-2 ), [6]
specifically, awake versus anesthetized, noninvasive versus invasive, and preservation of spontaneous
ventilation versus apnea. Although creation of a surgical airway in an awake patient is occasionally
necessary, the safest plan for most cases of anticipated airway difficulty is to perform awake tracheal
intubation under topical anesthesia. [67] The most versatile instrument for this technique is the FFL. The
threshold for using awake flexible fiberoptic intubation should be particularly low if surgery is urgent
(cancellation of surgery is not an option) or examination suggests that rescue techniques will be difficult or
Lack of patient cooperation precludes awake techniques. In these patients and if minor difficulty is anticipated
before elective surgery, general anesthesia may be induced by experienced anesthesiologists, but muscle
relaxants must be given until the airway has been secured. RILs may have a significant role in such patients.
Use of alternatives to tracheal intubation for patients with anticipated airway difficulty may be considered.
Inhaled induction and maintenance of facemask anesthesia for minor surgery of short duration in a fasted
patient is a good technique for a skilled user. The hazards of using SADs in such patients have been
considered. Use of regional anesthesia in patients with an anticipated difficult airway does not remove the
airway problem and carries the risk that failure of the regional technique (including increased duration or
extension of surgery) could result in the need for difficult intraoperative tracheal intubation under suboptimal
conditions (see Box 50-4 ).

Unanticipated Difficult Intubation

Unanticipated difficulty with direct laryngoscopy cannot be prevented, and a management strategy based on
a sufficient range of skills should be in place. All anesthesiologists should be skilled in at least one alternative
technique of tracheal intubation under vision. [47] [114] Strategies that include algorithms for the management
of unanticipated difficult intubation have been produced by several organizations, including the ASA and the
Difficult Airway Society (DAS), a U.K. organization. The ASA algorithm is the standard guide (see Fig. 50-2 ).
A great merit of the DAS algorithm [52] ( Fig. 50-19 ) is its simplicity and emphasis on progression through a
series of defined plans. Plan C, awakening the patient and postponing elective surgery, is an important
means of maintaining oxygenation and preventing trauma. The choice of techniques within the plans is less
important than the underling principles and strategy. Organizations and individuals should use evidence to
select appropriate techniques within the strategy. However, guidelines cannot achieve their aims without
good training. Some departments have produced their own guidelines, accompanied by a training program,
and report excellent results. [46] [63]


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Figure 50-19 Basic algorithm of the Difficult Airway Society (DAS) guidelines for the management of unanticipated difficult
tracheal intubation. (From Henderson JJ, Popat MT, Latto IP, et al: Difficult Airway Society guidelines for management of the
unanticipated difficult intubation. Anaesthesia 59:675-694, 2004.)

The most difficult situation is management of unanticipated airway difficulty in a patient requiring emergency
surgery. The risks of delaying surgery must be balanced against the risk of proceeding with a suboptimal
airway. If it is essential to proceed with surgery, a traditional technique has been to continue with a facemask
and oral airway while maintaining cricoid pressure. Continuation of anesthesia with an LMAc is now an
established technique, though not always effective. Insertion of SADs is impeded by cricoid pressure, [115]
[116] which should be reduced as necessary during insertion and then reapplied at a level that allows
satisfactory function. The PLMA forms a better seal than the LMAc does and provides improved protection
against aspiration. It may be preferred by users who have proven competence with the device. Early
conversion to tracheal intubation with devices such as the AIC is desirable.

Cannot Intubate, Cannot Ventilate Situation

This situation may be defined as one in which ventilation with noninvasive techniques fails to maintain
oxygenation and tracheal intubation proves impossible. This scenario may develop rapidly but often occurs
after repeated unsuccessful attempts at intubation. [64]
Before resorting to invasive percutaneous airway techniques, maximum effort must be made to achieve
ventilation and oxygenation with noninvasive techniques, such as optimum mask ventilation and use of
SADs. Facemask ventilation may require the two-person technique and the use of an oral or nasal airway. It
may be necessary to reduce cricoid pressure to achieve satisfactory ventilation. If satisfactory oxygenation


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cannot be achieved with a facemask, an SAD should be used instead. Insertion of an LMA in the cannot
intubate, cannot ventilate situation has a significant failure rate. [43]
The risks associated with an invasive rescue technique must be constantly weighed against the risk of
hypoxic brain damage or death. Rapid development of severe hypoxemia, particularly when associated with
bradycardia, is an indication for imminent insertion of a percutaneous airway that can reliably deliver a large
minute volume with an FIO2 of 1.0. Many cricothyrotomy techniques have been criticized because they are
not capable of providing effective ventilation. [117] [118]
If noninvasive techniques do not restore oxygenation, cricothyrotomy is the percutaneous airway of choice [2]
because tracheotomy may take too long. It is not possible to define the SpO2 at which cricothyrotomy should
be performedit depends on the degree of hypoxemia and how rapidly it is deteriorating. [52] Cannula and
surgical cricothyrotomy each have advantages and disadvantages. Cannula cricothyrotomy carries a lower
risk of significant bleeding. It may be considered when dedicated equipment is immediately available and
staff are fully trained in its use. However, it may fail or cause barotrauma. [2] If it cannot be performed rapidly,
is ineffective, [2] or causes complications, [2] surgical cricothyrotomy should be performed immediately. [2]
Surgical cricothyrotomy with insertion of a cuffed tube is more invasive but can be performed very rapidly and
allows effective ventilation with low-pressure sources.
Emergency invasive airway access is a temporary measure to restore oxygenation and will be followed by
definitive airway management. This may be a formal tracheotomy, but tracheal intubation is possible in some

Airway management is at the core of care of anesthetized and unconscious patients. Though straightforward
much of the time, it can be very difficult. Many new devices and techniques have become available, and their
strengths and weaknesses have become apparent. Editorials have emphasized the need for skills in an
increased range of techniques of tracheal intubation. [67] [114] The range of equipment available, development
and maintenance of skills, and organizational factors such as appropriate allocation of personnel are
important safety issues.
Concern has been expressed about the airway skills of trainees, but experienced anesthesiologists have also
been slow to develop and maintain airway skills in new techniques of proven value. [119] Popat stated that
most anaesthetists continue to use high-risk strategies as a consequence of a limited range of skills. Skills
with the combination of the Macintosh laryngoscope, LMA and introducer are not sufficient core skills to allow
safe airway management of all patients. [67] Crosby stated that there is a population of patients for whom
exclusive reliance on direct laryngoscopy is a high-risk strategy resulting in morbidity and occasional mortality
Q We should emphasise practitioners developing experience and a high comfort level with a limited number
of alternatives. [114] However, there is hope. Departments that give sufficient time and resources to the
development of airway skills have reported excellent results. [46] [47] [63] We should seek to emulate the safety
culture of the airline industry, wherein regular practice is used to train staff to deal with infrequent
emergenciesThere is no excuse for poorly designed procedures when human life is at risk. [120]

Many airway devices have been introduced over the last few decades. Every effort has been made to include
the most important devices, but it is possible that some have been omitted inadvertently. Omission of any
such device does not imply that it might not be useful in clinical management. New devices are produced
regularly and readers must research the market.

Statement of Interest
The author has received royalties from sales of the Henderson laryngoscope.

I am grateful to many colleagues who have provided useful criticism. Michelle McNicol worked to a very high
standard to create new drawings.


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