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AIRWAY MANAGEMENT
1. Anatomy
a. Upper airway: pharynx, nose, mouth, larynx,
trachea, main-stem bronchi
b. There are two openings to the human airway:
the nose (leads to nasopharynx) and the
mouth (leads to oropharynx). They are
separated anteriorly by the palate
c. Pharynx is a U-shaped fibromuscular structure
that extends from the base of the skull to the
cricoid cartilage at the entrance to the
esophagus.
d. Nasopharynx is separated from the
oropharynx by an imaginary plane that
extends posteriorly
e. The epiglottis functionally separates the
oropharynx from the laryngopharynx and prevents aspiration by covering the glottis
when swallowing.
f. The larynx is a cargilaginous skeleton held by ligaments and muscles. It is composed
of nine cartilages: thyroid (shields conus elasticus which forms vocal cord), cricoid,
epiglottic, and (in pairs) arytenoid, corniculate, and cuneiform.
g. Sensory supply:
i. Mucous membranes of nose: CN V.1 anteriorly and V.2 posteriorly
ii. Superior and inferior surface of hard and soft palate: palatine nerves
iii. Nasal mucosa: CN I
iv. Anterior 2/3 of tongue: CN V.3 with branches of CN VII, Posterior 1/3 of
tongue: CN IX
v. Superior laryngeal branch of vagus nerve divides into:
1. External (motor) nerve (cricothyroid muscle)
2. Internal (sensory) laryngeal nerve
Provides sensory supply to the larynx between epiglottis and vocal cords
vi. Recurrent laryngeal nerve: innervates larynx below the vocal cords and
trachea
1. Innervates the muscles of larynx except the cricothyroid muscle
VP
A. Airway Assessment
a. First step in successful airway management
b. Assessments include:
i. Mouth opening: incisor distance of 3cm or greater is desirable in
adult
ii. Upper lip bite test: lower teeth are brought in front of the upper
teeth. This estimates the range of motion of the TMJ
iii. Mallampati classification: examines the size of the tongue in relation
to oral cavity. The greater the tongue obstruction the more difficult
intubation may be.
1. Class 1: Entire palatal arch including the bilateral faucial
pillars are visible down to their bases
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B. Equipment:
a. The following equipment is routinely needed in airway mangement
situations:
i. Oxygen source
ii. BMV capability
iii. Laryngoscopes (direct and video)
iv. Several endotracheal tubes of different sizes
v. Other (not ETT) airway devices (oral, nasal airways)
vi. Suction
vii. Oximetry and CO2 detection
viii. Stethoscope
ix. Tape
x. Blood pressure and electrocardiography monitors
xi. IV access
b. Oral and nasal airways:
i. Loss of upper airway muscle tone in anesthetized patients allow the
tongue and epiglottis to fall back against the posterior wall of the
pharynx
ii. Repositioning the head or jaw thrust is preferred technique for
opening the airway
iii. Awake or lightly anesthetized patient with intact laryngeal reflex
may cough or even develop laryngospasm during airway insertion!
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c. Orotracheal intubation:
i. Laryngoscope is held with left hand, and blade is introduced to right
side of oropharynx (avoid the teeth!) with the tongue swept to the
left and up into the floor of pharynx
ii. Tip of curved blade is inserted into vallecula, and straight blade tip
covers the epiglottis
iii. Handle is raised up and away from patient perpendicular to
patient’s mandible to expose vocal cords
iv. Avoid -> trapping lip between teeth and blade or leverage on the
teeth
v. TT is taken with right hand and its tip is passed through the vocal
cords. Backward-upward-rightward-pressure (BURP) procedure can
be done to monve an anteriorly positioned glottis posterior to
facilitate visualization of glottis.
vi. TT cuff should lie in the upper trachea, beyond the larynx
vii. While withdrawing laryngoscope, avoid tooth damage!
viii. Cuff is inflated with least amount of air to create seal during positive
pressure ventilation to minimize pressure damage to trachea
(Overinflation >30mmHg may inhibit capilary blood flow of trachea)
ix. Immediately ausculate the chest and epigastrium, and put on
capnographic tracking (definitive test) to ensure intratracheal
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d. Nasotracheal intubation:
i. TT is advanced through nostril patient can breathe with–
nasopharynx – oropharynx before laryngoscopy
ii. Phenylephrine nose drop (0.5% or 0.25%) vasoconstrict vessels and
shirnk mucous membranes
iii. If patient is awake, then apply local anesthetic ointment (for nostril),
spray (for oropharynx), and nerve blocks
iv. TT lubricated with water-soluble jelly is introduced along the floor of
the nose below inferior turbinate at an angle perpendicular to the
face.
v. To ensure tube passes along the floor of nasal cavity, the proximal
end should be pulled cephalad
vi. Proceed until tip can be seen in oropharynx
vii. Laryngoscopy reveals the abducted vocal cords and TT is pushed
onwards. If there is difficulty, then tip of the tube may be directed
with Magill forceps but be careful not to damage the cuffs
viii. Great risk if patient has midfacial trauma -> intracranial placement
VP
I. Techniques of extubation:
a. Most often, should be performed when patient is either deeply anesthetized
or awake -> adequate recovery from neuromuscular blocking agents should
be established
b. Extubation during light plane of anesthesia (antara deep and awake) is
avoided because increased risk of laryngospasm
c. To differentiate, suction the pharyngeal cavity. If there is reaction (cough,
holding breath) means the patient is in a state of light plane. If no reaction,
the patient is in a deep state
d. Eye opening or purposeful movements imply that the patient is sufficiently
awake for extubation -> associated with coughing on the TT
i. Increases heart rate
ii. Increases central venous pressure
iii. Increases arterial blood pressure
iv. Increases intracranial pressure
v. Increases intraabdominal pressure
vi. Increases intraocular pressure
vii. Can cause wound dehiscence and increased bleeding
viii. Presence of TT in asthmatic patient -> bronchospasm
ix. Decrease these effects by administering 1.5mg/kg IV lidocaine 1-2
minutes before suctioning and extubation
e. Patient’s pharynx should be suctioned prior to extubation to prevent
aspiration of mucous or blood into the lungs
f. Ventilate with 100% O2 in case it will be difficult to establish airway after TT
removal
g. Remember to remove the tape and uncuff the TT prior to extubation, and
remove the TT in a single smooth motion
J. Complication of laryngoscopy and intubation:
a. Airway trauma
i. Tooth damage is common
cause of malpractice claims
ii. Laryngoscopy and intubation
-> sore throat to tracheal
stenosis due to prolonged
external pressure -> tissue
ischemia, inflammation,
ulceration, granulation, and
hence stenosis.
iii. Cuff pressure of 20mmHg is
adequte to reduce
bloodflow to site by 75%. It
can be diminished by
hypotension
iv. Postintubation croup caused
by glottic, laryngeal, or
tracheal edema -> serious in
children. Efficacy of
corticosteroid
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