1. AIRWAY MANAGEMENT
Dr. Shankar. Hippargi
Consultant
Dept. of A & E

2. Anatomy

3. Anatomy
• Vocal cords divide the airway into upper and
lower airway
• Opening between the two vocal cords is called
Glottis
• Glottis is the narrowest part in an adult airway

4. Age Considerations- Infant airway
• Large occiput
• Tongue relatively larger
• Larynx is higher in the neck (C3 in infants, C4-
C5 in adults)
• Subglottic area is the narrowest part
• Trachea is placed more anteriorily
• Young infants have relatively less oxygen
reserve (greater oxygen consumption), so
hypoxemia occurs more rapidly

5. Physiologic changes- Pregnancy
• Generalized edematous state which also affects
tongue & supraglottic soft tissue
• Mucosal engorgement- Bleeding & swelling
• Increased gastric emptying time & diminished
LES tone- Risk of aspiration
• Incidence of Mallampati class 3 increases as
pregnancy progresses
• Hypoxemia occurs more rapidly.

6. Problems with the emergency airway
• Unexpected
• Little time
• Panic
• Risk of Aspiration high
• Trauma:
 Facial injuries
 Head injuries
 C-Spine injuries
All the above situations makes it difficult to
secure the airway

7. CONSEQUENCES OF INADEQUATE
AIRWAY
• Hypoxic / anoxic brain injury
• Aspiration
• Raised ICP & herniation.
• Acidosis
• Brain Death
• Cardiac arrest

8. Assessment
• Level of consciousness
• Foreign bodies, blood, secretions
• Suctioning if required
• Noisy breathing- compromised airway

9. ?
• What is the most
common cause of
airway obstruction
in unconscious
patients?

10. Airway obstruction
Universal sign of choking

11. Heimlich maneuver

12. Airway management
Manual methods:
• Head tilt & Chin lift
• Jaw Thrust ( Trauma)

13. Airway adjuncts
• Oropharyngeal airway
• Nasopharyngeal airway

14. Oropharyngeal airway
• Contraindicated in
patients with gag
reflex.

15. Nasopharyngeal airway
• Contraindicated in
patients with
basal skull #

16. Bag-Valve-Mask, pocket mask
Techniques:
• Mouth - to - Mask
• One person BVM
• Two person BVM
• Three person BVM
• PPV: Forcing air into a
patient, (with a positive
pressure) who is
breathing inadequately
or not breathing at all

17. Mouth to mask
Jaw thrust Head tilt–chin lift

18. Bag-Valve-Mask
• Adequate seal and ensuring adequate tidal
volume is very important
• Look for equal & adequate chest rise
• Use Sellick’s maneuver to decrease gastric
distention

19. Single person BVM

20. Two person BVM

21. Three person BVM

22. Cricoid pressure (Sellick’s maneuver)
• Applying firm
backward pressure
over cricoid
cartilage, to
compress the
esophagus, to
prevent gastric
distension

23. Advanced airway
• Endotracheal Intubation
• LMA
• Combitube
• Fibreoptic
• Video laryngoscope

24. Surgical Airway
• Cricothyroidotomy
• Tracheostomy

25. INTUBATION
When does the patient need it?
• Unconscious/semiconscious patient with GCS <9
• Respiratory failure (snake bite, drug overdose)
• All gasping patients
• Cardiac arrest
• Anaphylaxis
• Pulmonary edema/ARDS for Positive pressure ventilation
• Before gastric lavage, in poisoning patients with low GCS

26. Purpose of intubation
• To maintain a patent airway
• To maintain adequate oxygenation
• Protect from aspiration
• For positive pressure ventilation
Note: It is the most definitive means of achieving
complete control of the airway

27. Airway assessment before intubating
(elective)
• Look for size of teeth
• Size & mobility of the jaw
• Mobility of C-spine (avoid in trauma)
• Short neck
• Obesity / pregnancy
• Mallampati class

28. Mallampati classification

29. Preparation for intubation
• BSI precaution • BVM
• Suction • Anesthetic gel
• Airway adjuncts • Magill forceps
• Laryngoscope • Pulseoxymetry &
• ETT ECG Monitor
• Stylet • Emergency drugs
• Bougie • Cricothyroidotomy
equipments

30. Magill forceps
Bougie

31. Endo tracheal tube

32. Choose the appropriate ETT size
• Adult males 7.5 - 8.5
• Adult females 7 – 8
• For pediatric patients (1- 8 years)
ETT size= 4 + (age in years)
4
• Use uncuffed tubes in patients <8 years
• Subtract 0.5 for the appropriate size cuffed
ETT

34. Positioning the patient

35. Intubation procedure
• Position : (sniffing position)
• Flexion at lower neck
• Extension at atlanto-occipital joint,
if there is no C- spine injury.
• Suspected C- spine injury:
• Manual in line stabilization should be
done

36. Procedure
• Pre oxygenate the patient adequately,
with 100% oxygen using BVM
• Hold laryngoscope in left hand and insert
laryngoscope blade into the right side of
mouth and sweep the tongue to left
• Lift the handle tangentially at 90o to the
blade
• Visualize vocal cords (BURP technique)

37. BURP technique
• Applying Backward, Upward and Rightward
Pressure over the lower third of thyroid
cartilage for proper visualization of the vocal
cords during intubation

38. Glottis
Visualize the tube going through this structure

40. Procedure
• After inserting the tube
• Take out the stylet, inflate cuff
• Ventilate patient through tube and confirm
breath sounds over epigastrium and 4 lung
fields. (5 point auscultation)
• If tube is placed properly, secure the tube in
place.

41. Rapid Sequence Intubation
Combined administration of sedative &
neuromuscular blocking agent to facilitate
tracheal intubation.

42. Rapid Sequence Intubation
• RSI should not be used in patients who do not
need pharmacological adjuvants for intubation
such as those with agonal respirations or
cardiac arrest
• Do not give RSI medication in whom
laryngoscopy is likely impossible
(Ex: Angioedema, Mallampati class 3 and 4)

43. Rapid Sequence Intubation
Preoxygenation:
• Hyperventilate at 20-24 breaths per minute with
100% O2, using BVM with a reservoir bag.
• Attain a saturation of over 95% before
administering any drugs.
• Perform Sellick’s maneuver before administering
the first RSI agent, and should be maintained
until tube is passed and cuff inflated

44. Inducing agent
• Sedation – Institutional choice
• Midazolam 0.1 mg/kg
• Thiopental 3 mg - 5 mg/kg
• Ketamine 1mg - 2mg/kg
• Propofol 0.5 to 1mg/kg

45. Paralyzing agent
• Immediately after the induction dose
• Succinylcholine 1 mg to 1.5 mg/kg
• Vecuronium 0.08mg to 0.15mg/kg
• Rocuronium 0.6 mg/kg

46. Succinylcholine
Advantages:
Rapid onset (45-60 sec)
Short duration (5-9min)
Watch for:
Brady arrhythmias, malignant hyperthermia,
hyperkalemia, cardiac arrest, increased ICP,
IOP, intra gastric pressure

47. Special considerations
• Give Atropine 0.02 mg/kg IV for pediatric
patients to prevent bradycardia & asystole
• Give Lidocaine 1.5mg/kg IV, if raised ICP is
anticipated (head injury, meningitis, SOL in
brain)

48. Confirming the tube placement
• Five point auscultation
• Look for equal chest rise
• End tidal CO2 detectors
• Esophageal detector devices
Note: Visualizing the tube going through the
cords is the best method of confirmation

49. Misplaced ETT
• Right main stem intubation:
- Breath Sounds more on right side
- Deflate cuff, pull back about 1
inch, reinflate, ventilate and reconfirm
• Esophageal intubation:
- Sounds primarily over epigastium
- Deflate cuff, remove tube
- Hyperventilate patient for another 1-2
minutes,
- Reintubate

50. Other techniques of intubation
• Nasotracheal intubation- Blind procedure
• Trismus, TM joint arthritis,
• Risk of bleeding is high
• Difficult in apneic patients
• Patient may have sinusitis later

51. Digital intubation
• Indicated in children
and patients with
micrognathia
• Handy technique
when laryngoscope
is not available

52. Retrograde intubation
• Rarely required in
Mallampatti class 3
& 4 patients

53. Difficult Airway
• ANATOMICAL CONSIDERATIONS
• Limited cervical mobility
• Prominent upper incisors
• Limited jaw opening
• Receding mandible (micrognathia)
• Facial trauma

54. Limited Cervical mobility

55. Limited Jaw Opening

56. Receding Mandible (micrognathia)

57. Facial Trauma

58. LMA
• Laryngeal mask airway
• Can be placed blindly
• Can provide PPV
• Effective alternative in
failed intubation.
• Can be inserted
without
manipulating patient’s
head.

59. LMA

60. Combitube
• Single tube with two lumens
• Can be inserted blindly
• Can provide PPV
• Effective alternative in failed intubation.
• Can be inserted without manipulating patient’s
head

61. Combitube

62. Combitube

63. Advanced airway devices

64. Surgical airway
• Needle cricothyroidotomy
• Surgical cricothyroidotomy
• Tracheostomy

65. Indications:
Failed intubation due to anatomy (short, obese
neck), disease states (epiglottitis, laryngeal
edema), trauma (C-Spine #, mandibular #)

66. Needle cricothyroidotomy
• Insertion of a large bore IV catheter through
the cricothyroid membrane.
• Easy to perform but greatly inferior in
providing adequate ventilation.
• Patients can be ventilated only for 20-30 mins.
• I:E ratio should be 1:10 to 1:15

68. Needle cricothyroidotomy

69. Surgical cricothyroidotomy
• Preferred over needle cricothyroidotomy.
• Contraindicated in children <12 years- late
airway complications
• Diameter of the tube inserted should not be
>7mm.
• If airway is needed for >3 days,
cricothyroidotomy should be changed to
tracheostomy

71. Surgical cricothyroidotomy
• Make a small vertical, or horizontal incision
over the skin and subcutaneous tissue.
• Perforate the cricothyroid membrane with the
blade,
• Place the back of the scalpel handle into the
incision to widen the opening
• Insert the ETT, inflate cuff and secure the tube
with adhesive tape

72. Surgical cricothyroidotomy
• The only vascular structure that may get
injured during the course of a properly
performed cricothyroidotomy is the thyroid
ima artery
• Rx- Surgical ligation

73. Tracheostomy

74. QUESTIONS ?

75. Thank you…