Airway Management

Presented By:
Mayur Jain
Introduction
 Difficulty in breathing is one of
the most disconcerting problems
for the patient who is conscious
yet unable to breath properly.
One needs to be aware of the
psychological aspect of the
patient while management of
airway obstruction.
Indications
Indications of Airway Management
Maxillofacial trauma
Aspiration of foreign body
Vasodepressor syncope
Asthma
Heart failure
Hypoglycemia
Overdose reaction
Anaphylaxis
Epilepsy
Diagnosis
 Diagnosis of Airway
Obstruction
LOOK : Respiratory
movements,
gasping ,
suprasternal
retraction
LISTEN: Breath
sounds
FEEL : Expired air
Diagnosis of Airway Obstruction
Abnormal sounds in airway
obstruction
◦ Snoring - due to obstruction of upper
airway by the tongue
◦ Gurgling - due to obstruction of upper
airway by liquids (blood, vomit)
◦ Wheezing - due to narrowing of the
lower airways
◦ Complete airway obstruction is silent.
Definition of Airway
management
Definition of Airway
management
“Airway management
involves ensuring that the patient
has a patent airway through
which effective ventilation can
take place.”
Purpose
Purpose
Deprived of oxygen; brain death will
occur within minutes.
To provide an artificial airway that is
as close to the patient's natural
airway as possible along with a
continuous source of oxygen.
Anatomy of Respiratory
System
Anatomy of Respiratory
System
The airways can be divided in to parts namely:
 The upper airway.
 The lower airway
The Upper Airway
A Epiglottis
B Mandible
C Frontal Sinus
D Soft Palate
E Trachea
F Glottis
G Esophagus
H Vocal Cords
The Upper Airway
 Other Structures
◦ Nasopharynx
◦ Oropharynx
◦ Laryngopharynx
◦ Larynx
The Upper Airway
Functions of the Upper
Airway
 Passageway for
air
 Warm
 Filter
 Humidify
 Protection
◦ Gag Reflex
◦ Cough
 Speech
The Lower Airway
Primary
A Bronchi
B Hyoid Bone
C Right Lung
D Secondary
E Bronchi
F Tracheal
G Ligament
H Trachea
I Larynx
J Esophagus
Left Lung
Trachea
Difference Between Adult And
Infant Airway

Adult Infant
Alveoli
 Gas Exchange
Lungs
 Structure
 Lobes
 Pleura
Mallampati Grades

Class I Class II Class III Class IV

⇑ Difficulty 

Class I: Uvula/tonsillar pillars visible

Class II: Tip of uvula/pillars hidden by tongue
Class III: Only soft palate visible
Class IV: Only hard palate visible
Airway management
procedures
Airway management
procedures
 A. Noninvasive procedures
1. Back Blows
2. Head Tilt Chin lift procedure
3. Heimlich maneuver (Abdominal thrust)
4. Chest thrust
5. Finger sweep
6. Ambu -Bag
 B. Invasive procedures
1. Oropharangeal airway
2. Nasopharangeal airway
3. Cricothyroidectomy
4. Tracheotomy
5. Endotracheal tube
6. Laryngeal Mask Airway
Non Invasive Procedures
Back Blows
Back Blows

◦ Indications:
Infants
◦ Contraindications:
Not recommended for Children and
adults
◦ Advantages
Ease
Back Blows
◦ Disadvantages
1.Not as effective as Heimlich
Maneuver
◦ Procedure
1.Hold the infant in one hand
2.Head lower than trunk
3.Support jaws
4.Blow with heel of hands between
shoulder blades
Back Blow Video
Heads Tilt Chin lift procedure
Head Tilt Chin lift procedure
Indications :
◦ To open the airway
Caution with :
◦ Suspected Neck injury
Procedure :
◦ One hand on forehead to tilt head
back
◦ With fingers of other hand Lift
mandible upward and outward
Heads Tilt Chin lift procedure:
Video
Heimlich maneuver
Heimlich maneuver
◦ Indications:
To remove foreign body.
◦ Advantages
Effective procedure
◦ Disadvantages
Injury to intra-abdominal organs
may occur
Heimlich maneuver
◦ Procedure
Conscious patient :
2.Position behind patient and wrap
arms around waist
3.Grasp one fist with other hand and
position it slightly above umbilicus;
caution- xiphoid process
4. Inward and upward thrusts until
foreign body is out.
Heimlich Manuever : Conscious
Patient Video
Heimlich manuever
Procedure
◦ Unconscious patient :
Patient positioned supine
Open airway by “head tilt technique”
Place heel of one hand on abdomen just
above the umbilicus and second hand on
top of that
4. Provide 6-10 thrusts.
Chest Thrust
Chest Thrust
◦ Indications:
1. Infant and child upto 8 years old
2. Pregnant female
3. Extreme obesity
◦ Contraindications:
1. Geriatric patients
◦ Advantages
1. Alternative to Heimlich Maneuver
Chest Thrust
◦ Procedure
Conscious victim :
2.Stand behind patient encircling
victim’s chest
3.Place same grip on middle of
sternum
4.Perform until foreign body is out
Chest Thrust
◦ Procedure
Unconscious victim :
2.Supine position
3.“Head tilt technique”
4.Same hand position on lower half
of sternum
5.6-10 downward thrusts
Jaw Thrust
Jaw Thrust
Indication :
◦ To open the airway blocked due to
tongue prolapse
Procedure :
◦ Grasp the angles of the lower jaw,
one hand on each side, and
displacing the mandible forward.
◦ Thumbs opening the mouth
Jaw Thrust Video
Finger sweep
Finger sweep
◦ Indications:
1. Removal of foreign body in
unconscious patients
◦ Contraindications:
1. Conscious patient
 Finger sweep

◦ Procedure
1.Supine position
2.Grasp tongue and anterio portion
of mandible, pull the tongue
3.Use index finger to dislodge the
foreign body
4.CAUTION: Don’t force the object
deep into airway
Ambu Bag
Ambu Bag
Indications:
◦ Unconscious patients
◦ Supplemental oxygen Source
Advantages :
◦ Can be used directly with
Endotracheal tube
Supplemental O2
◦ Allows spontaneous ventilation
Ambu Bag
Diasdvantages:
◦ Require special training
◦ Does not ensure adequate airway
Ambu Bag
Ambu Bag
Technique:
◦ Attach appropriate mask
◦ Ensure good seal
◦ Hold mask with one hand and
squeeze bag intermittently with
other hand
Ambu Bag
Recovery Position Video
Invasive Techniques
Invasive techniques
 Indications:
1. Failure of noninvasive techniques
2. Obstruction due to swelling;
laryngeal edema, epiglottitis
 Contraindications:
1. Inadequate training
2. Lack of proper equipments
Invasive Techniques
 Advantages
1. Higher success rate
 Disadvantages:
1. Need for expertise
2. Equipments
3. Cost
Risks/Protective Measures
Be prepared for:
◦ Coughing
◦ Spitting
◦ Vomiting
◦ Biting
Body Substance Isolation
◦ Gloves
◦ Face masks
◦ Eye shields
Oropharyngeal Airway
Oropharyngeal Airway
Indications :
◦ Unconscious but spontaneously
breathing patients due to tongue
positions
Advantages :
◦ Seperates tongue from posterior
pharyngeal wall
Disadvantages :
◦ Activates gag reflex in conscious
patients
Oropharyngeal Airway
Size :
◦ Adult : 100 mm
◦ Small adult : 80 – 90 mm

Technique :
◦ Position
◦ Use tongue blade
◦ Insert inverted and later rotate
Oropharyngeal Airway
Oropharyngeal Airway
Oropharyngeal Airway
Various Sizes
Oropharyngeal Airway
Nasopharyngeal Airway
Nasopharyngeal Airway
Indications:
◦ Tongue obstruction
◦ Inadequate oral opening
◦ Oral Surgery
Advantages :
◦ Well tolerated even in conscious
patient
Sizes : (Internal Diameter)
◦ Large adult :8-9 mm
◦ Small adult : 6-8 mm
Nasopharyngeal Airway
Nasopharyngeal Airway

Various Sizes
Nasopharyngeal Airway
Position
Determine the size of tubes
Local Anesthesia
Lubricate
Nasopharyngeal Airway
Nasopharyngeal Airway
Tracheotomy
Tracheostomy
Definition :
“Formation of a fistulas hole
between the skin and trachea”
Tracheostomy
Classification:
◦ Emergency Tracheostomy
◦ Semi-emergency Tracheostomy
◦ Planned Tracheostomy

◦ High Level : 1, 2, 3 tracheal rings

◦ Low Level : 2,3,4 tracheal rings

◦ Temporary : for respiratory distress

◦ Permanent :Laryngopharyngectomy
Tracheotomy
◦ Indications:
1. Long term airway maintenance
2. Glottic edema
3. Laryngeal nerve palsy
4. Head injury
5. Tetanus
6. Coma
7. Chest injury
8. Laryngeal infections
Tracheotomy
 Contraindications:
◦ Cervical Spine fracture
◦ Tracheomalecia
◦ Carcinoma of trachea
 Advantages
◦ Bypass upper airway obstruction
◦ Reduces the dead space
◦ Attachment to vetilator is possible
Tracheotomy

◦ Equipments :
2.Blade
3.Tracheal dilator
4.Cats paw retractor
5.Tracheostomy tube
Tracheotomy
 Technique :
◦ Patient position
◦ Hyperextension of neck
◦ Locate the cricoid cartilage
◦ Vertical incision of 2-3 cm
◦ Retract skin using Cat paw retractor
◦ Incise the trachea and dilate it using
tracheal dilator
◦ Apply 2% lignocain gauze ( Reflex)
◦ Insert the tracheotomy tubes
Tracheotomy
Completed
tracheotomy:
1 - Vocal cords
2 - Thyroid
cartilage
3 - Cricoid
cartilage
4 - Tracheal
cartilages
5 - Balloon cuff
Tracheotomy
◦ Possible Complications
1. Perforation of esophagus
2. Hemorrhage
3. Pnemothorax
4. Tracheal stenosis
5. Loss of speech
6. Chances of infection
Percutaneous
Tracheotomy
Procedure
◦ skin incision along relaxed skin
tension lines
◦ Insert of 14-gauge needle
◦ Tracheal dilatation
◦ Insert tracheostomy tube
◦ Connect ventilator tubing
Percutaneous
Tracheotomy
Cricothyrotomy
Cricothyrotomy
 Indications
◦ Absolute need for definitive airway, AND
unable to perform ETI due to structural or
anatomic reasons, AND
risk of not securing airway is > than surgical
airway risk
OR
◦ Absolute need for definitive airway AND
unable to clear an upper airway obstruction,
AND
multiple unsuccessful attempts at ETT, AND
other methods of ventilation do not allow for
effective ventilation, respiration
Cricothyrotomy
Contraindications (relative)
No real demonstrated indication
Risks > Benefits
Age < 8 years (some say 10, some say
12)
Evidence of fractured larynx or cricoid
cartilage
Evidence of tracheal transection
Advantages:
Less complications
Less bleeding
Heals within a few days
 Anatomy

Thyroidand cricoid
cartilages
Cricothyroid
membrane
Anatomy
Cricothyrotomy
 Equipments :
1. Scalpel No. 11 Blade
2. Or 13 gauge half inch long needle
Cricothyrotomy Video
Cricothyrotomy
 Technique:
1. Supine position
2. Hyperextension of neck
3. Locate cricothyroid membrane
4. Vertical skin incision
5. Retract with thumb and index finger
6. Horizontal incision as close to cricoid
cartilage as possible
7. Rotate the blade at 90 degrees
8. If available, insert tubes
Cricothyrotomy Video
Endotracheal intubation
Endotracheal Intubation

Introduction
◦ Tube into trachea to provide
ventilations using ventilator
Endotracheal Intubation
Definition :
◦ Endotracheal intubation is the placement
of a tube into the trachea (windpipe) in
order to maintain an open airway in
patients who are unconscious or unable to
breathe on their own. Oxygen, anesthetics,
or other gaseous medications can be
delivered through the tube.
Endotracheal Intubation
 Indications:
◦  Treatment of symptomatic hypercapnia.
◦ Treatment of symptomatic hypoxemia.
◦ Airway protection against aspiration.
◦ Pulmonary toilet
◦ Present or impending respiratory failure
◦ Apnea
◦ Unable to protect own airway
 Contraindications:
◦ Awake patient.
◦ Airway can be managed less invasively
Endotracheal Intubation

Advantages
◦ Secures airway
◦ Route for a few medications
◦ Optimizes ventilation, oxygenation
◦ Allows suctioning of lower airway
Hazards:
◦ Esophageal intubation
◦ Damage to vocal cords
◦ Damage to teeth (Laryngoscope)
◦ Endobroncheal intubation
Endotracheal Intubation
 Equipment:

2. Endotrachealtube
Adult female= 7- 8 mm
Adult Male = 8 – 9 mm
child = diameter of little finger
Endotracheal tube
Endotracheal Tube
Endotracheal Tubes
Endotracheal Tubes
Endotracheal Intubation
 Equipments
Laryngoscope blade
1. Stright
Adult : size 3 to 4
Child : Size 2-3
Baby : size 1- 2
2. Curved
1. Adult : size 3 to 4
2. Child : Size 2-3
3. Baby : size 1- 2
Laryngoscope

Curved Laryngoscope

Straight Laryngoscope
Curved Blade (Macintosh)

Insert from right to

left
Visualize anatomy
Blade in vallecula
Lift up and away
DO NOT PRY ON
TEETH
Lift epiglottis
indirectly
Straight Blade (Miller)

Insert from right to

left
Visualize anatomy
Blade past vallecula
and over epiglottis
Lift up and away
DO NOT PRY ON
TEETH
Lift epiglottis
directly
Intubation Technique
Vocal Cords
Laryngoscopy
Endotracheal Intubation
Procedure:
Assess
◦ airway – note landmarks, swelling,
deformities.
◦ Remove dentures. – Assess tongue size,
dental obstruction, visibility of oropharynx,
◦ degree of neck mobility. - Maintain cervical
spine stability as necessary.
Open airway: suction or manually
extract foreign material. – Chin lift, jaw
thrust.
Heimlich maneuver as needed.
Endotracheal Intubation
Position patient into “sniffing
position” if possible; restrain as
necessary.
Standing at the supine patient’s
head, gentle insert laryngoscope
blade with left hand. 
Positioning
Positioning

Patient Positioning
◦ Goal
Align 3 planes of
view, so
Vocal cords are
most visible
◦ T - trachea
◦ P - Pharynx
◦ O - Oropharynx
Endotracheal Intubation
Endotracheal
Intubation
Visualize glottic opening/vocal
cords.
Insert the tubes
Endotracheal
Intubation
Endotracheal Intubation

Tip of blade is placed in vallecula, and laryngoscope

is lifted further to expose glottis. The tube is inserted
through the right side of the mouth.
Endotracheal Intubation

Tube is advanced through vocal cords into trachea.

Tube Placement
Endotracheal
Intubation
Inflate ETT cuff with 5 – 10 cc air
via syringe.
Ventilate with bag and oxygen.
Endotracheal Intubation

Tube is positioned so that cuff is below vocal

cords, and laryngoscope is removed.
Endotracheal Intubation

Methods for securing adhesive tape.

Endotracheal Intubation
Confirm tube placement
◦ chest auscultation,
◦ CO2 monitor
◦ chest x-ray.
 Endotracheal
Intubation
Complication: Prevention: Management:
Remove loose teeth Check chest x-ray to
Missing/broken prior; avoid using rule out aspiration.
teeth: upper teeth as
fulcrum for
laryngoscope blade.
Clenched teeth: Paralytic
medication.
Air leak: Check cuff prior to Inject more air or
beginning change tube over
procedure. guide wire.
 Endotracheal
Intubation
Inability to visualize Proper patient Reposition, choose a
vocal cords: positioning, proper different blade,
laryngoscope blade adequate suction,
size, proper cricoid pressure by
suctioning. assistant.
Esophageal Visualize cords. Remove tube, re-
intubation: oxygenate and
reinsert.
Laryngospasm: Spray vocal cords Benzodiazepine or
with 2% Lidocaine. paralytic
medication.
Failure to intubate: Have alternative
plan prepared:
cricothyrotomy.
Laryngeal Mask Airway
Laryngeal Mask Airway
Indications:
◦ General Anesthesia
◦ Emergency
◦ In patients trapped in sitting position
◦ Unsuccessful intubation
Disadvantages :
◦ Does not protect lung from
aspiration
Laryngeal Mask Airway
Laryngeal Mask Airway
Laryngeal Mask Airway
Procedure:
◦ Identify correct size
◦ Lubricate
◦ Anesthetize
◦ Extend neck
◦ Insert, follow the curvatures of oropharynx
and rest over pyriform fossa
◦ Inflate cuff
◦ Check position using sthethoscope
◦ Attach to ventilator apparatus
LMA Placement
LMA Placement
Pharmacology
Pharmacologic Assisted Intubation

Sedation
◦ Reduce anxiety
◦ Induce amnesia
◦ Depress gag reflex, spontaneous
breathing
◦ Used for
induction
anxious, agitated patient
◦ Contraindications
hypersensitivity
hypotension
Pharmacologic Assisted Intubation

Common Medications for

Sedation
◦ Benzodiazepines (diazepam,
midazolam)
◦ Narcotics (fentanyl)
◦ Anesthesia Induction Agents
Etomidate
Ketamine
Propofol (Diprivan®)
Pharmacologic Assisted Intubation

 Indications
When intubation required in patient
who:
is awake,
has gag reflex, or
is agitated, combative
 Contraindications
Most are specific to medication
Inability to ventilate once paralysis
induced
Pharmacologic Assisted Intubation
 Advantages
◦ Enables provider to intubate patients who
otherwise would be difficult, impossible to
intubate
◦ Minimizes patient resistance to intubation
◦ Reduces risk of laryngospasm
Disadvantages/Potential Complications
◦ Does not provide sedation, amnesia
◦ Provider unable to intubate, ventilate after
NMB
◦ Aspiration during procedure
◦ Difficult to detect motor seizure activity
◦ Side effects, adverse effects of specific
drugs
Pharmacologic Assisted Intubation

Mechanism of Action
◦ Acts at neuromuscular junction where
ACh normally allows nerve impulse
transmission
◦ Binds to nicotinic receptor sites on
skeletal muscle
◦ Blocks further action by ACh at receptor
sites
◦ These drugs brings about the
neuromuscular blockade
Pharmacologic Assisted Intubation

Common Used NMB Agents

◦ Depolarizing NMB agents
succinylcholine (Anectine®) : 2.0 mg/kg
result within 60 sec.
◦ Non-depolarizing NMB agents
vecuronium (Norcuron®) : 0.08-0.12
mg/kg
rocuronium (Zemuron®) : 1 mg/kg IV
pancuronium (Pavulon®) : 0.15 to 0.2
mg/kg IV
Pharmacologic Assisted Intubation

◦ Summarized Procedure
Prepare all equipment, medications while
ventilating patient
Hyperventilate
Administer induction/sedation agents
and pretreatment meds (e.g. lidocaine or
atropine)
Administer NMB agent
Intubate as usual
Continue NMB and sedation/analgesia
prn
Conclusion
The airway management
techniques may be very rarely
required in the “Dental Practice”,
but when required these
techniques differentiate between
the Life And Death of the patient.
Thus it is imperative for every
dental surgeon to have atleast
the basic knowledge of airway
management techniques.
Questions ???
References
 Textbook of Medical Emergencies, Malamed.
 Clinician’s Manual of Oral and Maxillofacial Su
 Performing endotracheal intubation, Cindy Go
 Tracheostomy and its variants, Dr.Praveen Ku
 www.wikipedia.com
 www.medicinenet.org
 www.anesthesiology.org
 www.emtb.com
 www.clarus-medical.com
 www.fotosearch.com
Thank You!