Airway Management

ASATT 2014

James Lamberg, DO
Overview
Airway anatomy
Airway equipment & management
Basic airway adjuncts
Supraglottic devices
Intubation through supraglottic devices
Difficult airway management
Basic algorithm
Exchange techniques
The Problem
ASA Closed Claims
Events Associated with Death and
Permanent Brain Damage
Difficult intubation
Inadequate ventilation/oxygenation
Esophageal intubation
Premature extubation
Aspiration
Airway obstruction
Respiratory related damaging events were
responsible for approximately 50% or more
of claims for death or brain damage before
1986.
Cheney FW, et al. Trends in anesthesia-related death and brain damage: A closed claims analysis. Anesthesiology. 2006 Dec;105(6):1081-6.
Working Towards A Solution
Improvements in monitoring
Pulse oximetry (SpO2)
End-tidal carbon dioxide (ETCO2)
Improvements in devices
Supraglottic airways (e.g. LMA)
Video laryngoscopes (e.g. GlideScope)
Improvements in education
ASA difficult airway management guidelines
Airway Anatomy
Upper Respiratory System by BruceBlaus. Wikimedia Commons. Creative Commons - CC BY 3.0. Accessed 03-Aug-2014.
Airway Anatomy
Nose
Primary route of breathing
Device placement risks nosebleed
Impairs view of airway
Route for device placement
Oral surgery
Limited mouth opening
Device placement contraindication
Basilar skull fracture
More than 30 cases of intracranial nasogastric tubes
Mortality rate about 2 out of 3
Gen PR, et al. Inadvertent intracranial placement of a nasogastric tube. J Oral Maxillofac Surg. 2004 Nov;62(11):1435-8.
Airway Anatomy
Pharynx
Nasopharynx and oropharynx
Basic airway adjuncts
Nasal pharyngeal airways (NPA)
Oral pharyngeal airways (OPA)
Obstruction
Tongue
Jaw thrust

Airway Anatomy
Larynx
Epiglottis, trachea, cartilage, vocal cords
Thyroid cartilage (Adams apple)
External landmark for invasive airway access
Devices
Supraglottic devices (e.g. LMA)
Route for device placement
Endotracheal intubation
Direct laryngoscopy (DL)
Indirect laryngoscopy
Optical (mirror, fiberoptic), video
Airway Anatomy
Trachea
Location of definitive airway placement
Indications for endotracheal intubation
Oxygenation (low SpO2)
Ventilation (high ETCO2)
Upper airway protection (unconscious)
Aspiration risk
Pregnancy, trauma, bowel obstruction,
diabetes, obesity
Airway Equipment & Management
Oropharyngeal airway
Standard
Guedel: single channel
Berman: double channel
Fiberoptic intubating
Ovassapian: groove for ETT removal
ETT size 9mm or smaller
Williams: no groove
ETT size 8.5mm or smaller
ETT adapter must be removed
Airway Equipment & Management
Airway Equipment & Management
Nasopharyngeal airway
Standard soft
Adaptation for fiberoptic
Lengthwise slit
Adaptation for ventilation
15mm ETT adapter
Airway Equipment & Management
Airway Equipment & Management
Airway Equipment & Management
Passive oxygen delivery
Nasal cannula
2-6LPM gives 24-44% oxygen
Face mask
Give 28-70% oxygen depending on type
Delivery oxygen only
They do not assist ventilation (ETCO2)
Case: 75yoF in PACU s/p hip repair
100% O2 via ETT and reservoir bag
3.5hr postop ABG: 6.65 / 213 / 265 / 29
Ayas N, et al. Unrecognized severe postoperative hypercapnia: a case of apneic oxygenation. Mayo Clin Proc. 1998;73:51-4
Airway Equipment & Management
Positive pressure masks
Oxygenation and ventilation
Require tight seal
Standard 15mm/22mm connector
Manual resuscitation bags (i.e. BVM)
Self-inflating
Anesthesia machine
Not self-inflating
Adjustable pressure limiting (APL) valve
Pop-off valve
Airway Equipment & Management
Airway Equipment & Management
Supraglottic airways
Laryngeal mask airway (LMA)
Minimized oropharyngeal obstruction
Tracheal intubation avoided
Blind insertion
Aspiration risk
Integral part of emergency airway algorithm
Intubation through LMA
Exchange techniques
Airway Equipment & Management
Supraglottic airways
Esophageal tracheal Combitube (ETC)
Double lumen tubes
Can be confusing to new users
Two balloons
Tracheal
Esophageal
Blind insertion
ETT exchange requires balloon deflation
Airway Equipment & Management
Supraglottic airways
Laryngeal tube (LT)
Single lumen
One pilot balloon
Fills distal (esophageal) and proximal (pharyngeal)
Blind insertion
ETT exchange does not require balloon
deflation
Airway Equipment & Management
Airway Equipment & Management
Airway Equipment & Management
Airway Equipment & Management
Endotracheal tube (ETT)
Standard: Murphy eye to side
Parker: midline curve tip
RAE: Ring, Adair, & Elwyn
Magill forceps may be needed
Armored: prevent kinking
Can remain kinked if damaged/bitten
MLT: Microlaryngeal tracheal
Larger cuff, increased length
Intubation through LMA
Airway Equipment & Management
Airway Equipment & Management
Airway Equipment & Management
Intubation through LMA
Blind/exchange catheter
Flexible bronchoscope
LMA Unique Size Patient Size Largest ETT
#1 < 5kg 3.5mm ID
#2 10-20kg 4.5mm ID
#3 30-50kg 6.0mm ID
#4 50-70kg 6.0mm ID
#5 70-100kg 7.0mm ID
#6 > 100kg 7.0mm ID
Airway Equipment & Management
Laryngoscope
Direct (standard)
Indirect
Video
Examples: McGRATH, GlideScope
Optical stylet
Example: Shikani
Flexible bronchoscope (fiberoptic)
Airway Equipment & Management
Other Approaches
Conduits
Tracheal tube introducer (bougie)
Exchange catheter
Fiberoptic intubation catheter
Lighted stylet
Invasive access
Retrograde wire
Direct cricothyrotomy
Jet ventilation
3mL syringe + 7mm ETT adapter
Difficult Airway Management
Key points
Preparation
Communication
Consider options
Awake intubation vs after induction
Non-invasive vs invasive initial approach
Spontaneous breathing vs apnea
Difficult Airway Management
Awake Intubation
Non-Invasive Intubation
Succeed
Fail
Cancel Case
Consider Feasibility
of Other Options
Invasive Airway
Access
Invasive Airway Access
Apfelbaum JL, et al. Practice guidelines for management of the difficult airway. Anesthesiology. 2013 Feb;118(2):251-70.
Difficult Airway Management
Intubation After Induction
Succeed Fail
Consider:
1) Calling for help
2) Returning to spontaneous ventilation
3) Awakening the patient
Apfelbaum JL, et al. Practice guidelines for management of the difficult airway. Anesthesiology. 2013 Feb;118(2):251-70.
Difficult Airway Management
Intubation After Induction
Face Mask Adequate
Non-Emergency Pathway
Ventilation Adequate, Intubation Unsuccessful
Alternative Approaches
- Alternative Devices
- Exchange Techniques
Succeed Fail
Invasive airway access?
Consider other options?
Awaken patient?
Apfelbaum JL, et al. Practice guidelines for management of the difficult airway. Anesthesiology. 2013 Feb;118(2):251-70.
Difficult Airway Management
Intubation After Induction
Face Mask Not Adequate
Consider/Attempt
Supraglottic Device
Succeed
Non-Emergency Pathway
Fail
Emergency Pathway
Apfelbaum JL, et al. Practice guidelines for management of the difficult airway. Anesthesiology. 2013 Feb;118(2):251-70.
Difficult Airway Management
Exchange techniques
Aintree through LMA
LMA placed as a rescue device
ETT required for surgery or aspiration risk
Aintree through LT
LT placed prior to hospital arrival
Exchange for definitive airway (ETT)
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Difficult Airway Management
Video of exchange techniques here
Difficult Airway Management
Team dynamics
Clear communication
Closed loop, repeating back a request
OK, Im setting up the scope
Confirming requests
Would you like a size 4 LMA?
Feel empowered
Tunnel vision may divert focus
The ECG looks different
References
1) The Anesthesia Technician and Technologist's
Manual, Principles of Airway Management, Michael
Aziz, 1st Edition

2) The Anesthesia Technician and Technologist's
Manual, Airway Equipment Setup, Norman Torres,
1st Edition

3) The Anesthesia Technician and Technologist's
Manual, Airway Emergencies, Dawn Dillman, 1st
Edition

4) Miller's Anesthesia, Airway Management in the
Adult, John Henderson, 7th Edition
Thank You
Questions?