John Henderson
50 Airway Management in the Adult
Key Points
1. 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.
2. Conditions requiring particular caution include lesions at
the base of the tongue, recent onset of hoarseness, upper
airway obstruction, and obstructive sleep apnea.
3. 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 (ASA).
4. 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.
5. 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.
Anesthesia was developed to enable the performance of therapeu-
tic 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 neces-
sarily associated with depression of other physiologic systems.
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.
6. 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.
7. 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.
8. 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 deteriorating.
The depressant effects on airway, respiratory, and cardiovascular
function can cause immediate threats to the patient. Airway man-
agement differs from management of other depressed function in
that it requires a range of manual skills, as well as knowledge and
judgment.
1573
IV 1574 Anesthesia Management
Some components of anesthesia respiratory care have
become safer in the last 3 decades. American Society of Anesthe-
siologists (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 tra-
cheal intubation has more than doubled.1 The probable explana-
tion is that monitoring has reduced the number of adverse
outcomes from nonspecific events but prevention of adverse tra-
cheal intubation outcomes is more difficult. Evidence of the limita-
tions of traditional techniques has accrued and effective new
techniques have been developed. However, many anesthesiologists
continue to rely on multiple attempts with ineffective techniques.
Anatomy
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 para-
nasal sinuses. Prolonged nasotracheal intubation impairs drain-
age through these openings, causing sinusitis. The lining of the
nasal cavity is very vascular, and application of nasal vasocon-
strictors to shrink the mucosa and dilate the airway reduces the
risk of hemorrhage during the insertion of airway devices or tra-
cheal 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 manage-
ment.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 sub-
sequent opening by sliding (also known as protrusion, transloca-
tion, 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.
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 esopha-
gus 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
Figure 50-1 Scissors maneuver. The rotation and sliding components of the
temporomandibular joint are used to achieve maximal mouth opening.
can impinge on the posterior wall of the nasopharynx, and appli-
cation of increasing force when resistance is met can cause sub-
mucosal 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 respira-
tory tract from alimentary contents and later developed into an
organ of speech. The larynx bulges posteriorly into the laryn-
gopharynx, 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 and arytenoid
cartilage. The arytenoid cartilage sits on the posterolateral border
of the cricoid, from where it can be dislocated4 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 liga-
ment 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 hyoepiglot-
tic ligament to achieve indirect elevation of the epiglottis.
During swallowing the larynx is protected by several mech-
anisms. The larynx is tucked up behind the tongue, and the epi-
glottis 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 supe-
rior and recurrent laryngeal nerves. The superior laryngeal nerve
can be anesthetized at the point where it passes through the thy-
rohyoid 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 adja-
cent 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
trachea.
Airway Assessment
Three basic decisions (Fig. 50-2) needed before induction of
anesthesia in every patient6 are whether
To use awake endotracheal intubation
To use a percutaneous technique
To maintain spontaneous ventilation
These three strategies are safer than the use of an intrave-
nous 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 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 ana-
tomic 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 patho-
logic airway but is not practicable for routine assessment.
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 previ-
ous airway difficulty. A history of previous airway difficulty has a
higher positive predictive value and lower negative predictive
Airway Management in the Adult 1575 50
value than any tests.7 However, a history of previous easy laryn-
goscopy 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 assess-
Section IV Anesthesia Management
ment of mouth opening and jaw protrusion.9 Mouth opening is
measured as the interincisor distance, and a value of 4cm (2 fin-
gerbreadths) has been proposed as an indicator of probable diffi-
cult 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) extension10
impairs direct laryngoscopy. It can be measured as the angle
between the occlusal surface of the maxillary teeth and the hori-
zontal, 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 over-
estimated. The Mallampati test (visibility of pharyngeal struc-
tures) is of limited value on its own11 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 exami-
nation ensures that the laryngeal cartilage is palpated and sub-
mandibular 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 El-Ganzouri and
colleagues7 (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 per-
formed 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 pre-
dictors of moderate or severe difficulty with mask ventilation.
Snoring and a thyromental distance of less than 6cm are inde-
pendent predictors of severe difficulty.15 No test can accurately
predict complete failure of mask ventilation because its preva-
lence 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 manage-
ment 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 laryn-
goscopy 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 laryn-
goscopy, mask ventilation, and creation of a surgical airway has
many limitations. The causes of difficult laryngoscopy are multi-
factorial, and single tests have limited value11 as predictors. Pre-
diction is improved by combining the results of different tests.8
IV 1576 Anesthesia Management

Difficult Airway Algorithm

1. Assess the likelihood and clinical impact of basic management problems:
A. Difficult ventilation
B. Difficult intubation
C. Difficulty with patient cooperation or consent
D. Difficult tracheostomy
2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management:
3. Consider the relative merits and feasibility of basic management choices:

Awake intubation vs. Intubation attempts after induction

of general anesthesia
A
Noninvasive technique for initial Invasive technique for initial
vs.
B approach to intubation approach to intubation

Preservation of spontaneous Ablation of spontaneous

vs.
ventilation ventilation
C
4. Develop primary and alternative strategies:

A Awake intubation
B Intubation attempts after
induction of general anesthesia

Airway approached by Invasive

non-invasive intubation airway access(b)* Initial intubation Initial intubation
attempts successful* attempts UNsuccessful

Succeed* FAIL From this point

onwards, consider:
1. Calling for help 3. Awakening
2. Returning to the patient
Cancel Consider feasibility Invasive spontaneous ventilation
case of other options(a) airway access(b)*

Face mask ventilation Face mask ventilation

adequate not adequate

Nonemergency pathway LMA adequate* Consider/attempt LMA LMA not adequate

ventilation adequate, or not feasible
intubation successful

Emergency pathway
ventilation not adequate,
intubation unsuccessful

Alternative approaches If both face mask

to intubation(c) and LMA ventilation Call for help
become inadequate

Emergency non-invasive
airway ventilation(e)
Successful intubation* FAIL after multiple attempts

Successful ventilation* FAIL

Invasive airway Consider feasibility Awaken
access(b)* of other options(a) patient(d)
Emergency invasive
airway access(b)*
*Confirm ventilation, tracheal intubation, or LMA placement with exhaled CO2
a. Other options include (but are not limited to) surgery utilizing face b. Invasive airway access includes surgical or percutaneous d. Consider re-preparation of the patient for
mask or LMA anesthesia, local anesthesia infiltration, and regional tracheostomy or cricothyrotomy. awake intubation or canceling surgery.
nerve blockade. Pursuit of these options usually implies that mask c. Alternative noninvasive approaches to difficult intubation include e. Options for emergency noninvasive airway
ventilation will not be problematic. Therefore, these options may be (but are not limited to) use of different larynoscope blades, LMA ventilation include (but are not limited to): rigid
of limited value if this step in the algorithm has beed reached via as an intubation conduit (with or without fiberoptic guidance), bronchoscope, esophageal-tracheal Combitube
the Emergency Pathway. fiberoptic intubation, intubating stylet or tube changer, light wand, ventilation, or transtracheal jet vantilation.
retrograde intubation, and blind oral or nasal intubation.

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, 2003.)

Scores7,8 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 importance. It is more meaningful to
describe the result of individual tests. Airway assessment cannot
detect some serious problems, including asymptomatic lesions2,3
in the vicinity of the larynx, skeletal factors, and some varieties
of TMJ dysfunction.
The problem with airway assessment is that the risk of dif-
ficulty is overestimated and not all cases of difficult airway man-
agement 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 Chal-
lenging 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 back-
ward 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 struc-
tures anteriorly and relieve airway obstruction to a variable extent.
Jaw thrust is also effective in reducing obstruction at the velo-
pharynx in slim but not in obese patients. The lateral position can
be used alternatively or in addition to the aforementioned tech-
niques to allow the obstructing tissues to move downward so that
obstruction is reduced.16
There is now evidence of an additional dynamic compo-
nent 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 spon-
taneous 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 inter-
vening pharynx can occur when muscle tone is reduced. The
structure of a collapsible segment between two rigid tubes corre-
sponds 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.
Airway Management in the Adult 1577 50
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 pres-
sure (CPAP) reduces dynamic upper airway obstruction. Nasopha-
ryngeal airways might reduce this dynamic airway obstruction.
Section IV Anesthesia Management
Laryngospasm
Laryngospasm (reflex closure of the true vocal cords alone or
with the false cords because of stimulation of the intrinsic laryn-
geal muscles) can result from the combination of reflex hyperac-
tivity 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 signifi-
cant proportion of postoperative critical events. Morbidity and
mortality may result from the immediate (hypoxemia and hyper-
capnia) and delayed (negative-pressure pulmonary edema) con-
sequences of laryngospasm, and thus every effort should be made
to rapidly relieve the airway obstruction caused by laryngo
spasm.18 Management is discussed later.
Negative-pressure pulmonary edema18 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 ven-
tilation are sometimes required.
Oxygenation and Preoxygenation
Hypoxemia can occur in the time between induction of anesthe-
sia 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 preoxygena-
tion (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 preoxygena-
tion 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 cap-
nograph waveform. Wherever possible, the end-tidal oxygen con-
centration should be used as a guide to the adequacy of
preoxygenation, with a value of 90% being well accepted. Preoxy-
genation 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
IV 1578 Anesthesia Management
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 reduc-
tion 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 grad-
ually. 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 ventila-
tion has been recommended when sevoflurane is used. Prior
administration of topical anesthesia (e.g., 4% lidocaine, 3 to
5mL) 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 parti-
tion coefficient and causes minimal airway irritation, which facili-
tates 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. Further-
more, 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 obstruc-
tion, 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 cricothyrot-
omy 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 airways.
Intravenous Anesthesia with
Neuromuscular Blocking Drugs
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 pro-
vides good conditions rapidly in most patients inasmuch as neu-
romuscular blockade facilitates laryngoscopy, opens the vocal
cords, and prevents coughing. The high quality of intubating
conditions produced by NMBDs reduces the risk for postintuba-
tion 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 alterna-
tive 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 sugam-
madex 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 intuba-
tion 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 per-
formed 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 conditions26 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 uninter-
rupted 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. Seda-
tion 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 laryn-
goscope (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 dis-
comfort. This technique has become the standard for manage-
ment 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 techniques.
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
Box 50-1 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
Tracheotomy/Cricothyrotomy
Airway Management in the Adult 1579 50
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
Section IV Anesthesia Management
Combinations of the above
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 tech-
niques cannot be used or coughing is particularly undesirable.
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 post
operatively, 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 go (SAYGO)
technique. SAYGO is an intermittent application technique that
causes coughing and requires time for recovery after each applica-
tion. 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 fre-
quently 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 anesthe-
sia 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 mem-
brane 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 consider-
able 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
IV 1580 Anesthesia Management

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 patients 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 Figure 50-3 Oropharyngeal airway in place. The airway follows the curvature
the site and degree of obstruction and whether spontaneous of the tongue. It pulls the tongue and the epiglottis away from the posterior
breathing or positive-pressure ventilation is being used. Laryn- pharyngeal wall and provides a channel for the passage of air. (Adapted from
Dorsch JA, Dorsch SE: Understanding Anesthesia Equipment, 4th ed.
gospasm may be a component of airway obstruction and is con- Baltimore, Williams & Wilkins, 1999.)
sidered separately. The most important signs of airway obstruction
are clinical. Noisy respiration (snoring with supraglottic
obstruction and inspiratory stridor with glottic obstruction) is a If airway obstruction is not improved with the oropharyn-
classic sign of airway obstruction during spontaneous ventilation. geal airway, the next step has traditionally been insertion of a
However, noise depends on airflow, which is determined by the nasopharyngeal airway (Fig. 50-4), which often dramatically
degree of obstruction and the respiratory drive. Powerful inspira- improves the airway. Nasopharyngeal airways may be preferable
tion in the presence of airway obstruction produces the combina- to oropharyngeal airways in the presence of limited mouth
tion of inward movement of the upper chest region and outward opening and dental caries or gingivitis. Once in place, a nasopha-
movement of the lower chest and upper abdominal regions, ryngeal airway is less stimulating than an oral airway and better
thereby creating the classic seesaw movement sign. Powerful tolerated by lightly anesthetized patients. Insertion of a nasopha-
descent of the diaphragm in the presence of severe obstruction ryngeal airway can cause epistaxis as a consequence of damage
results in tracheal tug. Movement of the reservoir bag is a guide to the nasal mucosa, polyps, turbinates, or other tissues. This risk
to tidal volume, which can be supplemented by electronic meas- is minimized by gentle insertion of a well-lubricated small airway
urement. Reliance on the capnograph alone is dangerous. Serious and termination if resistance is met. Unless other measures fail to
hypercapnia caused by airway obstruction can exist despite a maintain an adequate airway, nasopharyngeal airways should not
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 struc-
tures 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 exert-
ing 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 some-
times required to overcome airway obstruction with head exten-
sion and jaw thrust. Use of the lateral position can dramatically
reduce airway obstruction.16
If head extension and jaw thrust fail to maintain an unob-
structed 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
Figure 50-4 The nasopharyngeal airway in place. The airway passes through
and laryngospasm. The risk of damage to the teeth during the the nose and ends at a point just above the epiglottis. (Adapted from Dorsch
insertion of oropharyngeal airways is increased in the presence JA, Dorsch SE: Understanding Anesthesia Equipment, 4th ed. Baltimore,
of caries and gingivitis. Williams & Wilkins, 1999.)

be used in patients with basal skull fracture because of the risk of
intracranial insertion. Ventilation through an SAD may be suc-
cessful when facemask ventilation fails. A laryngeal mask airway
(LMA) is now frequently inserted 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.
When airway obstruction makes facemask positive-
pressure ventilation difficult, any of the aforementioned maneu-
vers 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.
Laryngospasm during Anesthesia
The pathophysiology of laryngospasm has been discussed. Laryn-
gospasm 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. Obstruc-
tion 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 dis-
advantages 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., 0.1mg/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 indi-
cated. 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
Airway Management in the Adult 1581 50
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.
Section IV Anesthesia Management
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 esopha-
geal 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. Multiple- and 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 positive-pressure ventilation. The LT
has been used successfully in the cannot intubate, cannot venti-
late situation and LMA failure. A gastric drainage tube was added
in the Sonda models and perform well.31 Other esophageal obtu-
rator 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 com-
ponents: 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.
Technique
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 tech-
nique 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 recom-
mended for insertion of an LMA.
IV 1582 Anesthesia Management
A B
C D
Propofol or sevoflurane give good conditions for insertion
of an LMA. The combination provides particularly good condi-
tions with a low incidence of apnea and movement during inser-
tion.34 Short-acting narcotics improve the ease of insertion and
airway patency.35 Alfentanil (10g/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 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 rec-
ommended volume produces high cuff pressure and suboptimal
function. Inflation to a cuff pressure not higher than 60cm H2O
is recommended. The tube is connected to the anesthesia circuit
and gentle manual ventilation begun. Initial checks of LMA func-
tion are now performed. Lung expansion is observed. Slow refill
of the reservoir bag is a feature of airway obstruction. Ausculta-
tion 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 closure.
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 20cm H2O and the ability to
ventilate manually.36 Gas exchange and the possibility of obstruc-
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.)
tion are assessed by capnography, expired tidal volume, and the
flow-volume 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 deter-
mining the airway pressure at which gas escapes.
An effective seal depends on the size and position of the
LMA, inflation of the cuff, low airway resistance, and high pul-
monary compliance. Poor initial function may be caused by
laryngospasm or bronchospasm. Withdrawal followed by read-
vancement (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 undiag-
nosed 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 intubation.
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
Capnograph
Auscultation over the neck
Cuff leak pressure
Expired tidal volume and flow-volume loop
Examination with a flexible fiberoptic laryngoscope

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, epi-
glottis, 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 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 accept-
able or obstructed airways may be partly a consequence of dif-
ferences in clinical criteria. Airway obstruction unresponsive to
simple measures should be no more acceptable than with a face-
mask and should be relieved. Reversion to a facemask is often
effective. Emergency intraoperative tracheal intubation is some-
times necessary and is likely to be more hazardous than elective
intubation (Box 50-4).
Pulmonary Aspiration
The seal achieved by LMAs provides less protection against pul-
monary 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 regurgita-
tion 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-
Box 50-4 Hazards of Intraoperative Tracheal Intubation
SurgeryAdverse Effects
Interruption
Sterility, integrity, and outcome threatened
Tracheal Intubation Problems
Patient position suboptimal
Hypoxemia and risk of increased hypoxemia
Risk of tissue trauma
Airway Management in the Adult 1583 50
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
Section IV Anesthesia Management
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 intuba-
tion. 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 hemo-
dynamic stimulation than laryngoscopy and tracheal intubation
do. The LMA has advantages over tracheal intubation at the time
of extubation. The incidence of minor laryngopharyngeal mor-
bidity is similar with both devices. However, coughing is less
frequent at LMA than at tracheal tube removal, and adverse
hemodynamic effects 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 antici-
pated difficult airway has serious disadvantages. The difficult
airway remains and the development of airway obstruction could
produce a critical situation that requires immediate percutaneous
IV 1584 Anesthesia Management
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 fre-
quently difficult in patients in whom tracheal intubation is diffi-
cult. Use of an LMA when the patients position is other than
sniff will delay conversion to tracheal intubation when neces-
sary. 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 laryn-
goscopy for tracheal intubation. However, a tracheal tube is a
more reliable airway that provides better protection against pul-
monary 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 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 supe-
rior quality of airway. Airway seal pressure is increased by 50%
in relation to the LMAc, thus facilitating positive-pressure venti-
lation and probably providing better airway protection. The
device may be introduced digitally or with a special introducer.
An alternative laryngoscope introducer technique has been devel-
oped to prevent folding of the mask tip during insertion. A lubri-
cated 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
60cm 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 ineffec-
tive 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 alter-
native 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 20cm H2O. Addi-
tional checks unique to devices with a drainage tube may then be
performed. A thin layer of water-soluble 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 20cm H2O.
The drainage tube gel moves slightly when brief bobbing
pressure is applied to the suprasternal notch (the mecha-
nism is pressure on the esophagus).
Protection against Pulmonary Aspiration
The PLMA provides greater protection against pulmonary aspira-
tion 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 laparo-
scopic cholecystectomy has been advocated49 but is controver-
sial.41 Use of the PLMA for such surgery should be considered
only in patients who have no extra risk factors (including obesity,
symptomatic gastroesophageal reflux disease, reduced compli-
ance, increased airway resistance) for SAD use. The anesthesiolo-
gist 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
conflicting.
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 circula-
tory 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 inci-
dence of sore throat and hoarseness. Small tracheal tubes are
easier to insert than larger tubes and may cause less tissue pres-
sure 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 8mm (ID) for males and 7.5mm (ID) for females are often
used.
Airway Management in the Adult 1585 50
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
Section IV Anesthesia Management
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 particu-
larly important to prevent biting on such a tube.
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 dysfunc-
tion 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 range of 25 to
30cm 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 pulmo-
nary aspiration, but silent aspiration (micro-aspiration) of pha-
ryngeal 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 elimi-
nate 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.
IV 1586 Anesthesia Management
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 management
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
complications52:
1. 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.
2. Trauma must be prevented. The first attempt at tracheal
intubation should be performed under optimal conditions
(including patient position, preoxygenation, and equip-
ment preparation).53 The number of attempts with blind
techniques should ideally be zero and certainly not more
than four.
3. The anesthesiologist should have backup plans before start-
ing the primary technique6 and the skills and equipment
needed to execute these plans. When unanticipated diffi-
culty occurs in non-lifesaving surgery, the safest plan is
to terminate attempts at tracheal intubation, awaken the
patient, and postpone surgery.
4. The anesthesiologist should seek the best help available
(call for help) as soon as difficulty with tracheal intuba-
tion 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 aspira-
tion of pulmonary secretions is more difficult. Problems associ-
ated with prolonged duration of NTI include nasal damage, local
abscesses, otitis media, and sinusitis. The nasal route is contrain-
dicated 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 mini-
mize the incidence of complications peculiar to this route, includ-
ing 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 over-
come 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 proxi-
mal 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 ventila-
tion 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 intrave-
nous 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 laryn-

goscopes (RILs) can facilitate NTI under vision in patients in
whom this is not possible with direct laryngoscopes.
Direct Laryngoscopy: Theoretical Basis
Direct laryngoscopy is used to facilitate tracheal intubation under
vision. Successful direct laryngoscopy 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
laryngoscopy.
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
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.
Airway Management in the Adult 1587 50
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 posi-
tion 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
Section IV Anesthesia Management
maxillary teeth, improves the view of the larynx, and facilitates
full mouth opening. Head extension should be used unless there
is a contraindication.
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, Macintoshs 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 laryngoscope
and 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, erro-
neously described as a floppy epiglottis, and major difficulty
leads to complete failure to elevate the epiglottis with the conse-
quence 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 laryn-
goscope 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 indi-
rectly 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 maxil-
lary teeth because this may cause dental damage58 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.
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
IV 1588 Anesthesia Management
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.)
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 laryngo-
scope with external manipulation of the larynx), performed by
Epiglottis
Glottic
opening
Vocal
cords
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
the anesthesiologist who guides an assistant (Fig. 50-9), consist-
ently improves the laryngeal view. It is a key maneuver.
Tracheal Tube Passage with Successful
Macintosh Laryngoscopy
The view of the vocal cords is maintained while the anesthesiolo-
gist 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 tra-
cheal tube is advanced until the cuff is about 2cm distal to the
vocal cords. This position is important inasmuch as more proxi-
mal 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 con-
firmed. Cuff pressure is then adjusted to 25 to 30cm 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.
Right hand
of anesthesiologist
Right hand
of assistant
Figure 50-9 Bimanual laryngoscopy (external laryngeal manipulation). The
anesthesiologist guides the position and pressure exerted by the assistants
hand on the larynx to maximize view of the vocal cords. The left hand of the
anesthesiologist, which holds the laryngoscope handle, is omitted.

Difficulty with the Macintosh Technique
Difficulty with tracheal intubation is predominantly a conse-
quence of failure to see the larynx.53 The efficacy of direct laryn-
goscopy 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
pharyngeal wall and 3b when it cannot be lifted.59 This modifica-
tion of grade 3 is important in clinical practice because the intro-
ducer 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 when-
ever the initial view is unsatisfactory.
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 communi-
cate 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 obvious7 or anticipated61 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
Laryngoscope
Vocal cords
Posterior pharyngeal wall
Grade 1
Grade 2 Grade 3
Figure 50-10 Laryngoscopy view grades.
Airway Management in the Adult 1589 50
as increasing age, obesity, and modern dentistry. Anesthesiolo-
gists 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 eleva-
tion of the epiglottis will impair the efficacy of direct laryngos-
Section IV Anesthesia Management
copy. 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 diffi-
cult 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 val-
lecula and advancement of the laryngoscope displaced the epi-
glottis 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 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 intu-
bation 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
Epiglottis
Aryepiglottic fold
Posterior cartilage
Grade 4
IV 1590 Anesthesia Management
gum elastic bougies with an angulated tip, are passed (intro-
duced) into the trachea and then used as a guide for passage of
the tube. The introducer technique is relatively simple and incor-
porates verification of its blind passage down the trachea.52 It can
be divided into three parts: passage of the introducer, confirma-
tion of tracheal position, and passage of the tube over the intro-
ducer 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 verifica-
tion 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 laryn-
goscope 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 per-
mitted 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 evi-
dence of the efficacy of alternative techniques. There is now evi-
dence of high success rates of tracheal intubation under vision
with the straight laryngoscope,45 FFL,46 and RIL47 when the Mac-
intosh technique fails. Multiple blind attempts at tracheal intuba-
tion 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 dif-
ficulty can be a consequence of friable lesions such as lingual
tonsil hypertrophy.3 Use of blind techniques in such unpredicta-
ble 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, elec-
tive surgery should be postponed, the patient awakened, and sub-
sequent 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 intuba-
tion, 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 studies45
have reported successful tracheal intubation under vision with
the straight laryngoscope in patients in whom intubation proved
impossible with the Macintosh laryngoscope. Corroborative evi-
dence of the value of this technique comes from many reports of
successful use of the ENT straight laryngoscope and the rigid
bronchoscope in such patients.
The mechanism of the greater efficacy of the straight laryn-
goscope is probably both improved control of the tongue and
more reliable elevation of the epiglottis and is consistent with the
reduced force and head extension needed with the straight laryn-
goscope.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 moder-
ate lifting force to the laryngoscope handle helps maintain lateral
displacement of the tongue and reduces contact with the maxil-
lary 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. 50-11). This posi-
tion 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 laryn-
goscope blade (and in line of sight of the larynx). Under no cir-
cumstances 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 laryn-
goscope or tracheal intubation should be used.
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 tech-
nique 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

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.)
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 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 tra-
cheal 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
Airway Management in the Adult 1591 50
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.
Section IV Anesthesia Management
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 secre-
tions are common to all these devices. Modern indirect laryngo-
scopes 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 inser-
tion cord contains bundles of optical fibers that transmit the
image, a different group of optical fibers that transmit light to the
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 dis-
played 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 laryn-
goscope, but they function as FFLs and this term is used for
simplicity. Use of video monitors incurs greater expense than
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
IV 1592 Anesthesia Management
Epidural catheter
Diopter ring
Tracheal tube
Eye piece
Control lever
Light cable
Figure 50-12 Flexible fiberoptic laryngoscope.
reliance on eyepieces, but they facilitate teaching and ease of use
and may improve success rates.
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 intu-
bation trauma and postoperative upper airway edema. The FFL
in expert hands is well tolerated by an awake patient. Awake flex-
ible 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.
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 hypoventila-
tion, 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
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
Working channel
Light bundles
Lens covering viewing bundle
Flexible insertion cord
Bending section
Venting connector
To light source
effective and safe sedation in apprehensive or combative patients.
Remifentanil infusions have been used, but careful monitoring is
essential to prevent hypoventilation and hypoxemia.
Technique
The technique is summarized in Box 50-11. The patients position
may be supine, semisupine, or sitting (Fig. 50-13), and the anesthe-
siologist 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.
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 airways69 (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 anesthe-
Box 50-9 Advantages of Awake Patient State for Flexible
Fiberoptic Laryngoscopy
Spontaneous breathing continues
Oxygenation and ventilation maintained
Intubation easier
Anatomy and muscle tone preserved
Phonation as a guide
Safety
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
sia 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 vasoconstric-
tor 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.
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 airway and the fiberoptic laryngoscope is advanced under
vision between the vocal cords and into the trachea.
Airway Management in the Adult 1593 50
Box 50-11 Flexible Fiberoptic Laryngoscopy Technique
Drying agent
Effective topical anesthetic
Equipment check: lenses clean and focused, antifog agent
applied
Tracheal tube mounted
Section IV Anesthesia Management
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
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
IV 1594 Anesthesia Management
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 signifi-
cantly 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 esopha-
geal intubation. Tracheal intubation is confirmed by visualization
of the carina close to the end of the tracheal tube, and this dis-
tance is adjusted to 3 to 4cm. 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 retro-
grade 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 when that route is used.50 A technique involving
withdrawal of the tracheal tube 1 to 2cm, 90-degree anticlock-
wise rotation, and readvancement often achieves tracheal intuba-
tion 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 FFL50 and the type of tra-
cheal 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 tra-
cheal 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 tips 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 suc-
cessful, 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.
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 asso-
ciated with use of the FFL have been reported in closed claims.43
Complete airway obstruction during awake fiberoptic intuba-
tion 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
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.

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 manufac-
turers of devices that differ in many features. Video laryngo-
scope 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 technique73 and may
improve success rates. Ease of use is better because anesthesiolo-
gists 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, Upsher-
scope, 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 success-
ful in the presence of lingual tonsil hypertrophy or other laryn-
geal 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 50-14. 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.
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 manipu-
Airway Management in the Adult 1595 50
lating 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
Section IV Anesthesia Management
a hockey stick shape and 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 diffi-
cult, 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, tra-
cheal 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 posi-
tion, at the mouth again when passing the styletted tracheal tube
into the pharynx, and then at the monitor when passing the tra-
cheal tube into the trachea has been recommended75 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 advan-
tages 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 ante-
rior 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.
IV 1596 Anesthesia Management

A B

C D
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.

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 6mm (ID). The tracheal tube must also be
long enough for the cuff to lie 2cm 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 suf-
ficiently long and the cuff diameter is suitable for adult patients.
However positive-pressure ventilation during fiberoptic intuba-
tion 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 56cm 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 (7mm or larger) is then passed
over the AIC. The technique is mastered rapidly. The AIC has been
used successfully with other SADs.
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 8mm (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,
Aintree catheter
Flexible fiberoptic bundles to transmit an image from within the bowl of the mask
laryngoscope
Figure 50-15 Aintree intubating catheter within a flexible fiberoptic
laryngoscope, inserted through a laryngeal mask airway and advanced into
the trachea.
Airway Management in the Adult 1597 50
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 esophagus.
The technique of insertion of the ILMA differs in many
Section IV Anesthesia Management
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 anesthe-
sia 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 pha-
ryngeal 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 tech-
nique 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 cervi-
cal 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 intuba-
tion and is of proven value as a rescue device in cases of unan-
ticipated 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
C-Trach
The C-Trach is a variation of the ILMA that uses fiberoptic
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, inade-
quate light intensity, and obstruction of the view by the epiglot-
tis.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.
IV 1598 Anesthesia Management

Retrograde Intubation Positioning

mark
Positioning
The retrograde technique of intubation consists of percutane- mark
ously 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 A
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 Positioning
larynx has been successful after failure with a guidewire, and it is mark
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.
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 B
be confirmed by aspiration of air. Jaw thrust and tongue traction
can facilitate passage of the guide behind the tongue.
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 1cm below the vocal cords. Passage of a wider,
stiffer plastic sheath over the guide to act as an introducer for the
tracheal tube improves reliability. Excessive tension on the guide
may pull the tracheal tube anteriorly, thereby causing misalign-
ment 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, prob-
ably 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 C
bleeding. The guide may be threaded through the Murphy eye
and then passed up through the proximal lumen of the tracheal 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
tube. Pulling the tube after tying a knot inside the Murphy eye end of the guidewire is inserted in a cephalad direction until it exits the
has succeeded when other techniques have failed.84 mouth or nose. B, An 11.0 Fr Teflon catheter is threaded down over the
The retrograde technique has some disadvantages. It is guidewire until it contacts the laryngeal access site. The guidewire is
invasive and advancement of the tracheal tube is blind. It involves removed from above. C, After advancing the Teflon catheter 2 to 3cm, the
several steps and can take some time. The most frequent endotracheal tube is advanced into the trachea while maintaining constant
control of the catheter. (Courtesy of Cook Critical Care, Bloomington, IN.)
complications are minor bleeding, subcutaneous emphysema,
pneumomediastinum, and infection. Contraindications include
coagulopathy, inability to identify landmarks, laryngeal disease, awake intubation is indicated but sophisticated equipment is not
and local infection. Some have achieved high success rates with available.
the retrograde technique,84 but others have recorded low success
and significant complication rates.85
The great merit of the technique is its simplicity. It has little Lighted Stylet (Light-Guided Intubation)
place in elective practice in advanced hospitals. It may be the
technique of choice when the patient has pharyngeal bleeding The term lighted stylet may be used to describe any device that
and intubation is anticipated to be impossible. It is useful when uses a bright light within the tip of a tracheal tube as a guide to

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.
facilitate tracheal intubation.86 The technique depends on inter-
pretation of the light 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 obesity88 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.
Airway Management in the Adult 1599 50
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
Section IV Anesthesia Management
with tracheal intubation under light anesthesia. The magnitude of
the response is greater with increasing force and duration10 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 oro-
tracheal 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, 6g/kg,
suppress the hemodynamic response but risk prolonged respira-
tory depression. Aerosol or other application of topical anesthet-
ics may be beneficial with a low risk of adverse effects. Application
of such topical anesthesia may cause minor adverse hemody-
Thyroid cartilage
Access site
Cricoid cartilage
Posterior Anterior
Lateral view
Figure 50-18 Anatomy of the cricothyroid membrane. (Courtesy of Cook
Critical Care, Bloomington, IN.)
IV 1600 Anesthesia Management
namic effects, much less90 than those caused by tracheal intuba-
tion. 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 intu-
bation. Awake flexible fiberoptic intubation with effective topical
anesthesia almost eliminates the hemodynamic response to tra-
cheal intubation.
Direct arterial pressure monitoring throughout induction
of anesthesia is desirable in a high-risk patient so that the ane
sthesiologist 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 cardiovas-
cular monitoring and willingness to interrupt direct laryngoscopy
while anesthesia is deepened are keys to maintenance of reason-
able homeostasis.
Respiratory System
Protection of the lungs from pulmonary aspiration is a core func-
tion 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 bronchodilators91 reduce the broncho
constriction 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 cap-
nography is not available.
A gurgling sound with the first inflation suggests esopha-
geal intubation. Auscultation over the epigastrium and axillae is
usually reliable, but there are many sources of error93 and other
confirmation must be sought. Identification of CO2 in the expired
gas is the standard for verification of proper tracheal tube place-
ment, and a characteristic waveform over several breaths is sought.
However, there are many possible causes of false-negative 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 esopha-
gus 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 simplified94 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 intuba-
tion 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 diagnos-
tic. 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 diag-
nosis can still be difficult in patients with lung disease, and use of
the standard or simplified95 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 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 discon-
nection 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 con-
firmed 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 cath-
eter [AEC]) to prevent hypoventilation or pulmonary aspiration.
If intraoperative tube replacement is judged too dangerous, pha-
ryngeal 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.
Extubation
The tracheal tube (extubation) is removed when it is no longer
needed for airway protection. Timing and technique are influ-
enced 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, con-
tinued 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
Airway Management in the Adult 1601 50
Extubation may be performed at different depths of ane
sthesia, 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
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
Section IV Anesthesia Management
repair, is less likely with deep extubation. Upper airway obstruc-
tion 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 aspi-
ration, 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 anesthe-
sia 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 hyperten-
sion (with an associated increase in intracranial and ocular pres-
sure), 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 inci-
dence of these adverse effects. Narcotics, -adrenergic drugs, and
calcium channel blocking drugs have been studied most exten-
sively. 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 proce-
dures. Remifentanil also facilitates rapid recovery, early extuba-
tion, and high Spo2 values on admission to the postanesthesia
care unit.
Position
The sniff position is the standard position for extubation. Its
major advantage is that airway management, including reintuba-
tion, is optimized. The recovery (lateral) position may be a safer
option when there is an increased risk for pulmonary aspiration.
IV 1602 Anesthesia Management
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 dif-
ficult. 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 nega-
tive-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.
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 intra
operative management of laryngospasm in that use of intrave-
nous anesthetics will delay recovery. The Larson maneuver,
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
Preoxygenation
Secretions aspirated from the pharynx (the trachea also if
indicated)
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 respira-
tory 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 oxy-
genation, and reduce anxiety. The ratio of oxygen to helium
should be adjusted according to the clinical response.97 If hypox-
emia 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 intu-
bation 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 conse-
quence of airway obstruction and failure to reintubate.98 Impor-
tant 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
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 ven-
tilation 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 baro-
trauma.100 Although insufflation through AECs without baro-
trauma 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 tech-
niques fail to relieve the cannot intubate, cannot ventilate situa-
tion and severe increasing hypoxemia develops. Creation of a
percutaneous airway involves significant hazards.
Tracheotomy
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 trache-
otomy 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 inci-
sion 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
Airway Management in the Adult 1603 50
support. Dilatational tracheotomy is used frequently. Discussion
of the technique is beyond the scope of this chapter.
Cricothyrotomy
Cricothyrotomy creates a percutaneous airway through the cri-
cothyroid membrane. Its advantages over tracheotomy are that
Section IV Anesthesia Management
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. Cricothy-
rotomy 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 low-pressure ventilation with an
uncuffed tube is not guaranteed103). 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.
Seldinger Cricothyrotomy
Anesthesiologists are reluctant to perform emergency surgical
techniques, and thus Seldinger guidewire cricothyrotomy tech-
niques have been developed.103 These techniques are preferred by
Box 50-15 Surgical Cricothyrotomy
Equipment
No. 20 scalpel
Cuffed tracheal or tracheostomy tube with a 6- or 7-mm
internal diameter
Technique
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 scalpel
Step 4: Insert the tube and inflate the cuff
Step 5: Ventilate with a low-pressure source
Step 6: Confirm pulmonary ventilation
IV 1604 Anesthesia Management
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-pressure ventila-
tion. 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 aspira-
tion of air into a large syringe before the use of high-pressure
ventilation is essential. Subsequent dislodgement of the cannula
must be prevented.
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 4kPa (55psi) 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
Box 50-16 Cannula Cricothyrotomy
Equipment
Kink-resistant cannula
High-pressure ventilation system
Technique
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
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 miti-
gated by arranging good follow-up care.65 Damage to the glos-
sopharyngeal, hypoglossal, lingual, superior laryngeal, recurrent
laryngeal, mental, and branches of the trigeminal nerve has been
reported after airway management. This damage has been attrib-
uted to direct trauma or cuff pressure.
Less serious complications occur more frequently. Dental
damage is the most frequent cause of complaints against anesthe-
siologists,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 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 res-
piratory 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 elec-
tive 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 intuba-
tion 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 guidelines6
recommend that the anesthesiologist document the presence and
nature of any airway difficulty, inform the patient, and evaluate
and arrange appropriate management of complications. Docu-
mentation 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 notifi-
cation systems include a written report or letter to the patient, a
written report in the medical chart, and communication with the

patients surgeon or primary caregiver. Because only a warning
bracelet (e.g., www.medicalert.com) may be effective if the patient
is admitted unconscious to hospital, additional use of this system
is recommended.
Patients in whom laryngoscopy proves unexpectedly diffi-
cult are entitled to a diagnosis and appropriate management.
Fiberoptic nasendoscopy3,6 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 ret-
ropharyngeal 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 man-
agement, should be sterile to prevent cross-infection. The risk of
spreading prion disease with the use of contaminated medical
equipment107 is a particular problem because conventional clean-
ing and sterilization do not remove protein deposits from
equipment. Furthermore, sterilization can cause deterioration in
equipment performance, such as the effect of repeated autoclav-
ing 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 intro-
duced without evidence of efficacy. In the case of direct laryngo-
scopes, 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 rec-
ommended for rapid-sequence induction (RSI).
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 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 aspira-
tion of a small volume of pharyngeal contents to drowning sec-
ondary 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
Airway Management in the Adult 1605 50
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
Section IV Anesthesia Management
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 regurgi-
tation. Parkinsons 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
factors109; 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 pul-
monary 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 pul-
monary aspiration and the development of hypoxemia. Preoxy-
genation, 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 aspi-
ration 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 com-
pression 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 10N (a weight of
about 1kg, which is tolerable) when the patient is awake and then
increasing to 30N (about 3kg), 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 gener-
IV 1606 Anesthesia Management
ate 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, pos-
sibly 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
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 gastrointes-
tinal 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 gastroesopha-
geal 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 sur-
gical 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 impossible.
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 induc-
tion 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 antici-
pated 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 subop-
timal conditions (see Box 50-4).
Unanticipated Difficult Intubation
Unanticipated difficulty with direct laryngoscopy cannot be pre-
vented, 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 algo-
rithm52 (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 main-
taining oxygenation and preventing trauma. The choice of tech-
niques 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
The most difficult situation is management of unantici-
pated 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 aspira-
tion. 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 tra-
cheal intubation proves impossible. This scenario may develop
rapidly but often occurs after repeated unsuccessful attempts at
intubation.64
Before resorting to invasive percutaneous airway tech-
niques, 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
 Airway Management in the Adult 1607 50

Plan A: Succeed
Initial tracheal Direct laryngoscopy Tracheal intubation
intubation
Failed intubation

Succeed Confirmthen
Plan B:
Secondary tracheal ILMA or LMA fiberoptic tracheal
intubation plan intubation through
Failed oxygenation ILMA or LMA

Section IV Anesthesia Management

Plan C:
Maintenance of
oxygenation, ventilation,
postponement of
surgery and awakening
Plan D:
Rescue techniques for
cant intubate, cant
ventilate situation
Figure 50-19 Basic algorithm of the Difficult Airway
Succeed Society (DAS) guidelines for the management of
Revert to face mask Postpone surgery unanticipated difficult tracheal intubation. (From
Oxygenate and ventilate Awaken patient Henderson JJ, Popat MT, Latto IP, et al: Difficult
Airway Society guidelines for management of the
Failed oxygenation unanticipated difficult intubation. Anaesthesia 59:675-
694, 2004.)
Improved
oxygenation
Awaken patient
LMA
Increasing hypoxaemia
or

Cannula Surgical
cricothyroidotomy cricothyroidotomy
Fail

the two-person technique and the use of an oral or nasal airway.

It may be necessary to reduce cricoid pressure to achieve satisfac-
tory ventilation. If satisfactory oxygenation 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 tech-
niques have been criticized because they are not capable of pro-
viding effective ventilation.117,118
If noninvasive techniques do not restore oxygenation, cri-
cothyrotomy is the percutaneous airway of choice2 because tra-
cheotomy 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 disadvan-
tages. 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 patients.
Summary
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 popu-
lation of patients for whom exclusive reliance on direct laryngos-
copy is a high-risk strategy resulting in morbidity and occasional
mortality We should emphasise practitioners developing expe-
rience and a high comfort level with a limited number of alterna-
tives.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
IV 1608 Anesthesia Management
Caveats
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.
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Statement of Interest
The author has received royalties from sales of the Henderson
laryngoscope.
Acknowledgments
I am grateful to many colleagues who have provided useful criti-
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