AIRWAY MANAGEMENT

establishing, maintaining
& removing artificial
airway with
complications.
Dr. Chetan Goyal

AIRWAY MANAGEMENT
Assessment Mallampati score, mouth opening,
thyromental distance
Securing & maintenance airway devices
1.

Artificial airway

2.

Supraglottic airway devices

3.

Tracheal tube

4.

Devices for difficult airway

Management of complications

AIRWAY ASSESSMENT
Cervical spine movement
T-M joint movement
Mouth opening
Modified Mallampati grading
Thyromental distance

ARTIFICIAL AIRWAY
Purpose of an airway lift the tongue and epiglottis
away from the posterior pharyngeal wall.
Advantage of an airway
Cervical spine movement does not occur when
airway is inserted.
Decreased work of breathing during spontaneous
respiration using a face mask.
Oropharyngeal airway
Types

Nasopharyngeal airway

AIRWAY ANATOMY
A. Normal

B. Obstructed airway

OROPHARYNGEAL AIRWAY
Guedel airway
Parts flange, bite portion, air channel

OROPHARYNGEAL AIRWAY
(contd.)
Sizes available
Colour coding

Sizes

Length (mm)

000

30

00

40

50

60

70

80

90

100

110

OROPHARYNGEAL AIRWAYS
(contd.)
Uses
1)

To maintain open airway

2)

Prevent endotracheal tube occlusion

3)

Prevent tongue bite

4)

Facilitate suction

5)

Conduit for passing devices into oropharynx

6)

Obtain a better mask fit

Contraindications
1)

Intact gag reflex

2)

Oropharyngeal growth

OROPHARYNGEAL AIRWAY
Pre requisite for insertion(contd.)

Size estimation
Methods of insertion
Disadvantages 1) Due to incorrect size
2) Laryngospasm in awake patient
Advantages 1) Simple to use, cheap.
2) Not associated with sore throat
3) Does not cause bacteremia

NASOPHARYNGEAL AIRWAY
Parts flange, airway channel, bevel.
Size - inside diameter in millimeters.
Size determination
Method of insertion
Contraindications
1) Anticoagulation
2) Basilar skull fracture
3) Nasal pathology, sepsis, or deformity of the nose or
nasopharynx
4) History of epistaxis requiring medical treatment.

NASOPHARYNGEAL AIRWAY
(contd.)
Uses of nasopharyngeal airway
1.

To maintain airway in patients with intact gag reflex

2.

To facilitate suctioning

3.

As a guide for a fiberscope or nasogastric tube

4.

To apply continuous positive airway pressure (CPAP)

5.

To dilate the nasal passages in preparation for

nasotracheal intubation

6.

To maintain the airway and administer anesthesia

during dental surgery.

7.

To maintain ventilation during oral fiberoptic

endoscopy.

NASOPHARYNGEAL AIRWAY
(contd.)
Advantages1) Nasal airway is better tolerated than an oral
airway if the patient has intact airway reflexes.
2) Loose or poor dentition.
3) Trauma or pathology of the oral cavity.
4) It can be used when the mouth cannot be
opened.

COMPLICATIONS OF ARTIFICIAL AIRWAY

1)

Airway Obstruction

2)

Trauma

3)

Tissue Edema

4)

Ulceration and Necrosis

5)

Central Nervous System Trauma

6)

Dental Damage

7)

Laryngospasm and Coughing

8)

Retention, Aspiration, or Swallowing

9)

Devices Caught in Airway

10)

Equipment Failure

11)

Latex Allergy

12)

Gastric Distention

SUPRAGLOTTIC AIRWAY
DEVICES
Supraglottic devices fill a niche between the
face mask and tracheal tube in terms of both
anatomical position and degree of invasiveness.

These devices sit outside the trachea but

provide a handsfree means of achieving a gastight airway.

SUPRAGLOTTIC AIRWAY DEVICES

1)

Laryngeal Mask Airway Family

LMA Classic
LMA Unique
LMA Flexible
LMA Fastrach
LMA CTrach
LMA Proseal

2) Other supraglottic airways similar to laryngeal mask

Soft seal laryngeal mask
Ambu laryngeal mask
Intubating laryngeal airway
3) Other supraglottic airway devices
Laryngeal tube airway
Perilaryngeal airway
Streamlined pharynx airway liner

LARYNGEAL MASK AIRWAY FAMILY

LMA-Classic (standard LMA,

Classic LMA, LMA-C, cLMA)

PARTS

1. Curved tube (shaft)

2. Elliptical spoon-shaped mask
3. Two flexible vertical bars.
4. An inflatable cuff.
5. An inflation tube
6. Self-sealing pilot balloon.
7. 15-mm connector .

cLMA size

Patient size

Neonates/infants up to 5 kg

1.5

Infants between 5 and 10 kg

Infants/children between 10
and 20 kg

2.5

Children between 20 and 30 kg

Children 30 to 50 kg

Adults 50 to 70 kg

Adults 70 to 100 kg

Adults over 100 kg.

LMA CLASSIC

Insertion methods

1. Standard Technique
2. 180-degree Technique
3. Partial Inflation Technique
4. Thumb Insertion

Technique

LMA-UNIQUE

Disposable laryngeal mask airway, DLMA).

It is made of polyvinylchloride

The dimensions are identical to the standard LMA,

the tube is stiffer and the cuff less compliant.

Sizes

It may be a better choice for out-of-hospital or

ward use.

Insertion and placement of the LMA-Unique is

similar to the LMA-Classic.

The intracuff pressure increases significantly less

in the LMA-Unique when nitrous oxide is used.

LMA-FLEXIBLE

The LMA-Flexible (wire-reinforced, reinforced LMA, RLMA,

FLMA, flexible LMA) has a flexible, wire-reinforced tube.

The tube is longer and narrower.

Not available in sizes 1 and 1.5

Useful for head and neck surgeries

Insertion method

Disadvantages -

1) The wire reinforcement does not prevent obstruction from

biting.
2) The spiral reinforcing wire may become disrupted.
3) Only small sizes of tracheal tube or bronchoscope can pass
through it.
4) Not preferred prolonged spontaneous ventilation.
5) Unsuitable for MRI scanning
6) Malposition is less easily diagnosed .

LMA-FASTRACH

The LMA-Fastrach (intubating

LMA, ILMA, ILM, intubating
laryngeal mask airway)
designed for tracheal
intubation.

Parts

1) A short, curved stainless steel

shaft with a standard 15-mm
connector.
2) Single, movable epiglottic
elevator bar
3) A V-shaped guiding ramp built
into the floor of the mask.

LMA-FASTRACH

Insertion technique

Uses

1.

To facilitate tracheal intubation

2.

It can also be used as a primary airway device.

Tracheal Intubation using LMA Fastrach

1.

Blind,

2.

Blind nasal

3.

Fiberscopic guided

LMA-FASTRACH
Disadvantages
1. Pharyngeal pathology or limited mouth opening may

make intubation difficult.

2. Cannot be used for intubation in patients below 30 kg.

3. The LMA-Fastrach tracheal tube is expensive &

prolonged use is to be avoided.

4. The tracheal tube may be displaced downward or

dislodged.

5. It should not be used in the prone position

6. Unsuitable for use in the MRI unit.
7. Increased incidence of sore throat and difficulty

swallowing .

8. In patients with immobilized cervical spine, exerts

pressure on the cervical spine.

LMA-CTrach

It has two built-in fiberoptic channels with a

monitor.

Sizes - 3, 4, and 5

Insertion technique

Advantages

1)

High first intubation attempt success rate with

minimal neck movement.

2) Can be used during awake intubation in the

presence of an unstable cervical spine.

Disadvantages

1) Poor image quality

2) The view may be obstructed by secretions,
lubricant, or blood.
3) Cannot be used easily in the patient with a limited
mouth opening.

LMA-ProSeal

Parts - cuff, inflation line with

pilot balloon, airway tube, and
drain (gastric access) tube.

Function of second dorsal cuff

Insertion techniques introducer,

guided, digital methods

Confirmation of proper
placement

LMA-ProSeal
LMA Size

Weight (kg)

Max Cuff
Inflation
Volume
(mL)

Max.
Fiberoptic
Scope Size
(mm)

Max.
Length
gastric of Drain
Tube
Tube
Size (Fr)
(cm)

Largest
Tracheal
Tube (ID
in mm)

1.5

5 to 10

10

18.2

4.0
uncuffed

10 to 20

10

10

19.0

4.0
uncuffed

2.5

20 to 30

14

14

23.0

4.5
uncuffed

30 to 50

20

16

26.5

5.0
uncuffed

50 to 70

30

16

27.5

5.0
uncuffed

70 to 100

40

18

28.5

6.0 cuffed

LMA-ProSeal
Uses
1) Can be used for both spontaneous and controlled

ventilation.
2) Preferred in situations where higher airway

pressures are required, better airway protection is

desirable, and for surgical procedures in which
intraoperative gastric drainage or decompression is
needed
3) Useful in cases where it is important to avoid

airway trauma.
4) Safe for use in an MRI unit

LMA-ProSeal
Disadvantages 1) The LMA-ProSeal is less suitable as an intubation
device.
2) Higher resistance in spontaneously breathing
patients than other devices.
3) Requires a greater depth of anesthesia for insertion.
4) Airway obstruction after insertion.
5) Gastric insufflation
6) The LMA-ProSeal has a shorter life span.

LARYNGEAL TUBE AIRWAY

Parts

1) The airway tube is wide, curved,

color coded on the connector.

2) single lumen that is closed at the

tip.
3) Small (esophageal, distal) cuff near

the blind distal tip

4)

Large (oropharyngeal, pharyngeal)

cuff near the middle of the tube

LARYNGEAL TUBE AIRWAY (Cont.)

5) One inflation tube to inflate both light
blue cuffs.
6) Two anterior-facing, oval-shaped
openings (ventilation holes)
7) Side holes lateral to the top of the distal
opening.
8) A ramp leads from the posterior wall
toward the main ventilatory outlet
Reusable silicone or single-use
versions made of polyvinylchloride.

LARYNGEAL TUBE AIRWAY (Cont.)

Size

Patient

weight (kg)

Color of
Connector

Maximum
Cuff Volume
(mL)

neonate

<6

Transparent

15

infant

6 - 15

white

40

child

15 - 30

green

60

Small adult

30 - 60

yellow

120

Medium adult

50 90

red

130

Large adult

> 90

violet

150

LARYNGEAL TUBE AIRWAY (Cont.)

Insertion technique

Advantages -

1) The LT is relatively easy to insert

2) It is well tolerated during emergence
3) Because the distal cuff fits over the esophageal inlet, the
risk of gastric inflation is low
4) Can be used with both spontaneous and controlled
ventilation
5) High ventilation pressures can be used.

Laryngeal Tube Airway (Cont.)

6) This device may be especially useful for resuscitation
(cannot intubate, cannot ventilate situation ,
obstetrics after failed intubation, edentulous patients).
7) The incidence of complications such as sore throat,
mouth pain, or dysphagia is low.
8) Regurgitated liquid is less likely to be aspirated with the
LT

Disadvantage

1.

Failure to ventilate if tube enters trachea contrast

combitube

ENDOTRACHEAL TUBE

The tracheal tube (endotracheal

tube, intratracheal tube, tracheal
catheter) is a device that is inserted
through the larynx into the trachea
to convey gases and vapors to and
from the lungs.

Parts

1) The machine (proximal) end

2) The patient (tracheal or distal) end
3)

Bevel.

ENDOTRACHEAL TUBE
4) Murphy eye
5) A radiopaque marker
6) Cuff Systems consists of the cuff
plus an inflation
system, which
includes an inflation
tube, a pilot balloon,
and an inflation
valve.

ENDOTRACHEAL TUBE
Latex coated red rubber tubes

PVC tubes

Reused multiple times

Disposable

Not transparent

Transparent

Harden and become sticky with

age, poor resistance to kinking,
become clogged by dried
secretions

Less likely to kink than rubber

tubes. They are stiff enough for
intubation at room temperature but
soften at body temperature, so
they tend to conform to the
patient's upper airway.

Latex allergy in susceptible

patients

No latex allergy

ENDOTRACHEAL TUBE
Oral intubation
1.

Direct Laryngoscopy

2.

Blind Oral Intubation

3.

Digital Technique

4.

Fiberoptic guided

5.

Retrograde intubation

Nasal intubation
1.

Direct Laryngoscopy

2.

Flexible Fiberoptic Laryngoscopy

3.

Blind Nasal Intubation

EXTUBATION

The tracheal tube (extubation) is removed when it is no

longer needed for airway protection.

Extubation may be performed at different depths of

anesthesia - awake, light, and deep

Preparation for Extubation

Initial Plan
Patient position plan
Bite block in place
Throat pack removed
Preoxygenation
Secretions aspirated from the pharynx (the trachea also
if indicated)

EXTUBATION

Complications at Extubation

1.

Hypoventilation (residual effect of anesthetic drugs

and neuromuscular blockade)

2.

Upper airway obstruction

3.

Laryngospasm and bronchospasm

4.

Coughing (wound disruption)

5.

Impaired laryngeal competence and pulmonary

aspiration

6.

Hypertension, tachycardia, dysrhythmias,

myocardial ischemia

FLEXIBLE FIBEROPTIC BRONCHOSCOPY

Indications

1.

Difficult intubation predicted

2.

Congenital airway abnormalities

3.

Acquired airway abnormalities

4.

Trauma

Contraindications1.

Lack of time

2.

Blood & secretions in oral cavity

3.

Edema of pharynx or tongue

Technique oral or nasal (awake or GA)

COMBITUBE

Device for difficult airway

PARTS

1) Two separate lumens (pharyngeal &

tracheoesophageal) that are fused longitudinally
2) Two inflatable cuffs.
3) Each lumen is linked by a short tube to a standard
15-mm connector at the breathing system end.
4) Pharyngeal lumen - occluded distal end and eight
oval-shaped perforations (ventilating eyes)
between the cuffs, coloured blue.

COMBITUBE
5) Tracheoesophageal lumen patent distal end and a clear
tube.
6) The smaller distal cuff serves
to seal either the esophagus or
trachea, depending on its
placement.
7) The larger (pharyngeal) cuff
(balloon) is above the
perforations.
8) The pilot balloon for the
pharyngeal cuff is colored blue.

COMBITUBE

Sizes:

1. Regular (41 [Fr])

2. SA (37 Fr)

Recommended for patients with a height greater than 5 feet

(152 cm).

Not recommended for patients younger than 12 years of

age.

METHOD OF INSERTION

COMBITUBE

Indications

1.

Airway management in the difficult-to-intubate patient

2.

Massive airway bleeding or regurgitation.

3.

Limited access to the airway and limited mouth opening

4.

Cervical spine injury.

5.

Useful in entertainers in whom it is important to avoid

vocal cord damage.

6.

In cardiopulmonary resuscitation in both prehospital

and in-hospital settings.

7.

Cannot ventilate, cannot intubate situation.

8.

Can be used during percutaneous dilatational

tracheostomy or tracheotomy

COMBITUBE

Contraindications
1. Active pharyngeal or laryngeal reflexes
2. Oesophageal trauma or pathology
3. ingestion of corrosive agents
4. Oropharyngeal, pharyngeal, or hypopharyngeal
mass.

COMBITUBE

Advantages

1.

Time needed for insertion is short and less skill is

required

2.

Can be inserted in presence of blood or secretions in

the oropharynx.

3.

Provides comparable ventilation and improved

oxygenation to that of tracheal intubation

4.

It can be used by an anesthesia provider having limited

use of the left arm .

5.

It is well tolerated by the patient during emergence

from anesthesia.

6.

Its use is not associated with high levels of trace gases.

7.

Decreased risk of accidental extubation.

8.

The Combitube provides good but not complete

protection from aspiration

COMBITUBE

Disadvantages

1.

Tracheal suctioning or fiberoptic bronchoscopy is not

possible through the Combitube in the esophageal
position

2.

High airflow resistance

3.

Insertion and removal of the Combitube is associated

with a higher stress response

4.

Trauma to the airway and esophagus

5.

Sore throat and dysphagia.

6.

Unsuitable for use in a patient with latex allergy .

7.

The Combitube is expensive compared to other single

use devices.

RETROGRADE INTUBATION

Retrograde (translaryngeal-guided, guided

blind) intubation is an elective or emergency
technique for securing a difficult airway, either
alone or in conjunction with other techniques.

Retrograde intubation is a useful option in

patients who cannot be intubated by using
traditional techniques.

Procedure can be expected to take 5 minutes or

more for completion.

Retrograde intubation set

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

Indications

1.

Difficult intubations

2.

Airway trauma

3.

Oro - Pharyngeal bleed

4.

Cervical spine injury

RETROGRADE INTUBATION

1.

Complications
Sore throat

2.

Trauma

3.

Barotrauma

4.

Pretracheal abscess

5.

The tracheal tube may inadvertently slip out as

it is advanced

CRICOTHYROTOMY

Placing a device through the cricothyroid

membrane to gain control of the airway.

It is part of the ASA and Difficult Airway Society

difficult airway algorithms.

Techniques

1.

Needle Cricothyrotomy

2.

Percutaneous Dilatational Cricothyrotomy

3.

Surgical Cricothyrotomy

NEEDLE CRICOTHYROTOMY

Ventilation Techniques - Jet Ventilation

Devices

1.

A number of jet ventilation devices are commercially

available.

2.

Automatic Ventilator

3.

Manual Jet Ventilation Device

4.

Flowmeter

5.

Oxygen Flush

6.

Anesthesia Breathing System

7.

Manual Resuscitation Bag

Percutaneous Dilatational
Cricothyrotomy

CRICOTHYROTOMY

Indications

1.

Upper Airway Obstruction with Inability to

Ventilate or Intubate

2.

Anticipated Difficult Intubation - Cricothyrotomy

may be used as an adjunct to fiberoptic or other
intubation techniques where it is anticipated
that intubation may be difficult to perform.

3.

Procedures Involving the Airway

4.

Cervical Spine Injury

CRICOTHYROTOMY

Contraindications

1.

Intrathoracic Airway Obstruction

2.

Inability to Locate the Cricothyroid Membrane

3.

Complete Airway Obstruction

4.

Paediatric patients

5.

Laryngeal pathology

6.

Decreased compliance

CRICOTHYROTOMY

Advantages

1.

Simple, quick, easy to perform

2.

Prevents tracheal collapse

Disadvantage-

1.

Does not provide definitive airway

CRICOTHYROTOMY

Complications

1.

Barotrauma

2.

Trauma

3.

Subcutaneous / mediastinal emphysema

4.

Tracheal stoma granulation

5.

Persistent stoma

6.

Tracheal stenosis

7.

Dysphonia

8.

Vocal cord paresis

9.

Wound infection

American Society of Anesthesiologists Difficult Airway

Algorithm.

REFERENCES

Understanding anesthesia equipments Dorsch, 5th

edition

Millers text book of anesthesia 7th edition

Clinical anesthesia Morgan

CME Airway- MAMC

Airway management Rashid Khan