Speaker: Dr.

Shafat A Mir

Department of Anaesthesia And Critical Care

SKIMS ,Srinagar,j&k.India.
“Airway Management remains as much art as science”

Perhaps the most important

responsibility of the anesthesiologist
is “management of the patient‟s
airway”.
What should we know about “airway
management”?
● Airway anatomy and function
● Evaluation of airway
● Clinical management of the airway
- Maintenance and ventilation
- Intubation and extubation
- Difficult airway management
The term “airway” refers to the upper
airway consisting of

● Nasal and oral cavities

● Pharynx
● Larynx
● Trachea
● Principal bronchi
 UPPER AIRWAY
Frontal Sinus

Nasal Cavity
Nasopharynx
Nares
Oral cavity

Tongue Oropharynxc

Larynx
Epiglottis
Thyroid cartilage
Laryngopharynx
Cricoid cartilage

Trachea
 Soft Palate

Hard Palate

Palatopharyngeal Palatoglossal
Arch Arch

Oropharynx
Uvula

ORAL CAVITY
 Tongue
Lingual Tonsil

Base of tongue

Epiglottis Vallecula

Aryepiglottic fold Vestibular folds

(False Vocal Cords)
Glottis
True Vocal
Cords
Arytenoid Cartilage

Corniculate Cartilage

Esophagus
View of the base of the tongue, vallecula,
epiglottis, and vocal cords.
 Laryngeal Innervation
Nerve Sensory Motor
Superior Laryngeal Epiglottis, Base of tongue None
(internal division)
Supraglottic mucosa

Thyroepiglottic joint

Cricothyroid joint

Superior Laryngeal Anterior Subglottic Cricothyroid (adductor,

(external division) mucosa tensor)
Recurrent laryngeal Subglottic Mucosa Thyroarytenoid
Lateral cricoarytenoid
Interarytenoid (adductors)

Posterior cricoarytenoid
(abductor)
Laryngeal Innervations
Main, Lobar and Segmental Bronchi
EVALUATION OF
THE AIRWAY
1. History

2. Physical examination

3. Special Investigations
History:

• Previous history of difficult airway

• Airway-related untoward events

• Airway-related symptoms/diseases
Signs And Symptoms related to the
airway that should be sought:
Snoring (obstructive sleep apnoea)
Changes in voice
Stridor
Dysphagia
Chipped teeth
Cervical spine pain or limited range of motion
Upper extremity neuropathy
TMJ pain or dysfunction
 Evaluation of the Airway
General Physical Examination
Identify obvious problems such as:

•Massive obesity
•Short muscular neck
•Cervical collars
•Traction devices
•External trauma
•Indications of respiratory difficulty such as stridor.
•The presence of ear and hand anomalies
General airway assessment:
• Patency of nares

• Mouth opening

• Teeth

• Palate

• Ability to prognath

• Temporo-mandibular joint movement

 Syndrome Description
Down Large tongue, small mouth make
laryngoscopy difficult;
Small subglottic diameter possible
Laryngospasm is common

Goldenhar ( oculo-auriculo vertebral Mandibular hypoplasia and cervical spine

anomalies abnormality make laryngoscopy difficult.

Klippel Fiel Neck rigidity because of cervical vertebral

fusion
Pierre Robin Small mouth, large tongue, mandibular
anomaly; awake intubation essential in
neonate
Treacher Collins (mandibulofacial Laryngoscopy is difficult.
dysostosis)
Turners High likelihood of difficult intubation
Specific tests for assessment of airway:
A. Anatomical criteria

1. Relative tongue/pharyngeal size

Mallampatti test:
A. Class I : Visualization of the soft palate, fauces; uvula, anterior and
the posterior pillars.
B. Class II : Visualization of the soft palate, fauces and uvula.
C. Class III : Visualization of soft palate and base of uvula.

In Samsoon and Young’s modification (1987) of the Mallampati

classification, a IV class was added.
D. Class IV: Only hard palate is visible. Soft palate is not visible at all.
2. Atlanto occipital joint (AO) extension :

Grade I : >35°

Grade II : 22°-34°

Grade III : 12°-21°

Grade IV : < 12°

Normal angle of extension is 35° or more

3. Mandibular space:
i . Thyromental (T-M) distance (Patil’s test): This measurement helps in
determining how readily the laryngeal axis will fall in line with the pharyngeal axis
when the atlanto-occipital joint is extended. Alignment of these two axes is difficult if
the T-M distance is < 3 finger breadths or < 6 cm in adults; 6-6.5 cm is less difficult,
while > 6.5 cm is normal.

i i . Sterno-mental distance : Savva (1948) estimated the distance from the

suprasternal notch to the mentum. It is measured with the head fully extended on the
neck with the mouth closed. A value of less than 12 cm is found to predict a difficult
intubation.

i i i . Mandibulo-hyoid distance: Measurement of mandibular length from

chin (mental) to hyoid should be at least 4 cm or three finger breadths. It was found
that laryngoscopy became more difficult as the vertical distance between the mandible
and hyoid bone increased.

iv. Inter-incisor distance : It is the distance between the upper and lower
incisors. Normal is 4.6 cm or more; while > 3.8 cm predicts difficult airway.
 LEMON airway assessment method :
The score with a maximum of 10 points is calculated by assigning 1 point for each of the
following LEMON criteria:

L = Look externally (facial trauma, large incisors, beard or moustache, large

tongue).

E = Evaluate the 3-3-2 rule (incisor distance-3 finger breadths, hyoid-mental

distance-3 finger breadths, thyroid-to-mouth distance-2 finger breadths).

M = Mallampati (Mallampati score > 3).

O = Obstruction (presence of any condition like epiglottitis, peritonsillar abscess,

trauma).

N = Neck mobility (limited neck mobility).

Patients in the difficult intubation group have higher LEMON scores.

Radiographic assessment
1. From skeletal films
Lateral cervical x-ray film of the patients with head in neutral position closed is
required for the following measurement:

i . Mandibulo-hyoid distance :
An increase in the mandibulo-hyoid distance resulted in an increase in difficult
laryngoscopy.

i i . Atlanto-occipital gap :
A-O gap is the major factor which limits the extension of head on neck. Longer the
A-O gap, more space is available for mobility of head at that joint with good axis
for laryngoscopy and intubation. Radiologically there is reduced space between C1
and occiput.

i i i . Relation of mandibular angle and hyoid bone with cervical

vertebra and laryngoscopy grading :
A definite increase in difficult laryngoscopy was observed when the mandibular
angle tended to be more rostral and hyoid bone to be more caudal, position of
mandibular angle being more important.
iv. Anterior/Posterior depth of the mandible :
White and Kander (1975)18 have shown that the posterior depth of the
mandible i.e, the distance between the bony alveolus immediately behind
the 3rd molar tooth and the lower border of the mandible is an important
measure in determining the ease or difficulty of laryngoscopy.

v. Calcified ligaments:
Calcified stylohyoid ligaments are manifested by crease over hyoid bones
on radiological examination. Laryngoscopy is difficult because of inability
to lift the epiglottis from posterior pharyngeal wall as it is firmly attached
to the hyoid bone by the hyo-epiglottic ligament.
Fluoroscopy for dynamic imaging (cord mobility,
airway malacia, and emphysema).

Oesophagogram (inflammation, foreign body,

extensive mass or vascular ring).

Ultrasonography (assessment of anterior mediastinal

mass, lymphadenopathy, differentiates cyst from mass and
cellulitis from abscess).

Computed tomography/MRI (congenital anamolies,

vascular airway compression).

Video-optical intubation stylets (combines viewing

capability with the familiar handling of intubation
devices).
Compressed trachea
Wilson and colleagues developed another scoring system in
which they took 5 variables. Risk score was developed between 0
to 10. They found that higher the risk score, greater the accuracy of
prediction with a lower proportion of false positives.
Predictors of difficult airway in diabetics
Predictors of difficult airway are not the same in diabetics as in non-diabetic
groups.
i . Palm print:
The patient is made to sit;, palm and fingers of right hand are painted with
blue ink, patient then presses the hand firmly against a white paper placed on
a hard surface.

It is categorized as:
Grade 0 – All the phalangeal areas are visible.
Grade 1 – Deficiency in the interphalangeal areas of the 4th and 5th digits.
Grade 2 – Deficiency in interphalangeal areas of 2nd to 5th digits.
Grade 3 – Only the tips of digits are seen.

i i . Prayer sign: Patient is asked to bring both the palms together as

„Namaste‟ and sign is categorized as–

Positive – When there is gap between palms.

Negative – When there is no gap between palms.
Clinical Management of the Airway
Recognizing Upper Airway Obstruction

• Hoarse voice
• Decreased air in and out
• Stridor
• Retraction of suprasternal
/supraclavicular/intercostal space
• Tracheal tug
• Restlessness
• Cyanosis
 Opening the airway
1. Basic Airway Manoeuveres (without equipment) :-
Patient positioning
Head tilt / Chin lift/ Jaw thrust
2. With equipment :-

• Oro/Nasopharyngeal airway

• Endotracheal intubation

• Laryngeal mask airway (LMA)

• Combitube
The Anaesthetic Face Mask
Different Sizes Of face masks
The Oropharyngeal Airway
The nasopharyngeal airway in place
 Indication for tracheal intubation

● Airway protection

● Maintenance of patent airway

● Pulmonary toilet

● Application of positive pressure

● Maintenance of adequate oxygenation

• Checked anaesthesia machine (or oxygen source and
self-inflating resuscitator)
• Range of anaesthesia masks, LMAs, oropharyngeal and
nasopharyngeal airways
• Two checked laryngoscope handles
• Range of laryngoscope blades (Macintosh and straight)
• Range of tracheal tubes
• Stylet and introducer
• Syringe for cuff inflation
• Lubricant jelly
• Suction apparatus
• Magill forceps
• Tape to secure tube
• Capnograph
Schematic diagram demonstrating
the head position for endotracheal
intubation.

A.Successful direct laryngoscopy

for exposure of the glottic opening
requires alignment of the oral,
pharyngeal, and laryngeal axes.

B.Elevation of the head about 10

cm with pads below the occiput
and with the shoulders remaining
on the table aligns the laryngeal
and pharyngeal axes.

C. Subsequent head extension at

the atlanto-occipital joint
creates the shortest distance and
most nearly straight line from the
incisor teeth to glottic opening.
 Proper position of the laryngoscope blade during direct laryngoscopy
for exposure of the glottic opening.

A, The distal end of the curved blade is B, The distal end of the straight blade
advanced into the space between the (Jackson-Wisconsin or Miller) is advanced
base of the tongue and pharyngeal beneath the laryngeal surface of the epiglottis.
surface of the epiglottis (i.e., vallecula).
Regardless of blade design, forward and upward movement exerted along the axis of the
laryngoscope blade (arrows) elevates the epiglottis and exposes the glottic opening.
Optimum laryngeal view achieved with
the Macintosh laryngoscope. In this
figure the epiglottis has been allowed to
drop a little posteriorly to show the
laryngoscope in position in the vallecula.
 Optimization of view at direct laryngoscopy

• Maximum head extension

• Tongue entirely to the left of the laryngoscope
• Maximum mouth opening
• Optimum depth of laryngoscope insertion
• Maximum lifting force applied in the correct
direction
• ELM – applied with anaesthetist’s own right
hand
• Lift occiput with right hand
• Mandibular protrusion by assistant
Visual confirmation of tracheal
intubation
with the straight laryngoscope
Confirmation of tracheal intubation
•Techniques not requiring manual ventilation
•Inspection of the vocal cords
•Palpation of the trachea
•Use of esophageal detector device

•Techniques requiring manual ventilation

•Sounds
•Compliance
•Inspection of the chest
•Auscultation of the chest
•Auscultation of the epigastrium

•CO2 Detection
•Capnography

•Endoscopy

•Radiography
Examples of the most frequently used detachable laryngoscope blades,
which can be used interchangeably on the same handle. The upper blade is
the straight or Jackson-Wisconsin design. The middle blade incorporates a
curved distal tip (Miller). The lower blade is the curved or MacIntosh
blade. All three blades are available in lengths appropriate for neonates and
adults.
Laryngoscopes used with Macintosh technique.
Left to right are: Standard Macintosh (size 4), McCoy with tip elevated
and left-entry Macintosh. The styleted tracheal tube has been preformed
in the shape of an ice-hockey stick. The stylet must be plastic coated and
must not protrude beyond the tip of the tracheal tube.
Laryngoscopes used with paraglossal straight laryngoscopy
technique. Left to right: Miller, Belscope, Piquet-Crinquette-
Vilette (PCV) and Henderson.
Although the PCV has a gentle curve, it is possible to obtain a
LOS through the lumen. The PCV and Henderson have a semi-
tubular cross-section to facilitate passage of the tracheal tube.
Diagrammatic representation of
key distances relating to
endotracheal tube position.
Employed for patients at a particular risk for aspiration &
there is reasonable certainty that intubation should not be
difficult

Full stomach (<8-hour fast)

Trauma
Intra-abdominal pathology
Intestinal obstruction, inflammation
Gastric paresis (drugs, diabetes, uremia, infection)
Esophageal disease
Symptomatic reflux
Motility disorders
Pregnancy
Obesity
Uncertainty about intake of food or drink
1.Preoxygenation

2.Induction, Paralysis And Cricoid Pressure.

3.Confirmation of correct tube position.

Sellick maneuver
Defined as the clinical situation in which
a conventionally trained anesthesiologist
experiences difficulty with face mask
ventilation of the upper airway,
difficulty with tracheal intubation, or
both.
CORMACK LEHANE GRADING OF LARYNGOSCOPIC VIEWS
Massive Tongue Swelling requiring tracheostomy
Problems can arise with

Difficult ventilation

Difficult Intubation

Difficulty with patient cooperation or consent

Difficult tracheostomy
Techniques for difficult ventilation
Esophageal tracheal Combitube
Intratracheal jet stylet
Laryngeal mask airway
Oral and nasopharyngeal airways
Rigid ventilating bronchoscope
Invasive airway access
Transtracheal jet ventilation
Two-person mask ventilation
Techniques for difficult intubation

Alternative laryngoscope blades

Awake intubation
Blind intubation (oral or nasal)
Fiberoptic intubation
Intubating stylet or tube changer
Laryngeal mask airway as an
intubating conduit
Light wand
Retrograde intubation
Invasive airway access
 Suggested Contents of the Portable Storage Unit for
Difficult Airway Management

1. Rigid laryngoscope blades of alternate design and size from those

routinely used; this may include a rigid fiberoptic laryngoscope
2. Tracheal tubes of assorted sizes
3. Tracheal tube guides. Examples include (but are not limited to) semirigid
stylets, ventilating tube changer, light wands, and forceps designed to
manipulate the distal portion of the tracheal tube
4. Laryngeal mask airways of assorted sizes; this may include the intubating
laryngeal mask airway and the LMA-ProsealTM
5. Flexible fiberoptic intubation equipment
6. Retrograde intubation equipment
7. At least one device suitable for emergency noninvasive airway ventilation.
Examples include (but are not limited to) an esophageal tracheal
Combitube, a hollow jet ventilation stylet, and a transtracheal jet ventilator
8. Equipment suitable for emergency invasive airway access (e.g.,
cricothyrotomy)
9. An exhaled CO2 detector
Insertion of the laryngeal mask airway (LMA). A, The tip of the cuff is pressed upward against the
hard palate by the index finger while the middle finger opens the mouth. B, The LMA is pressed
backward in a smooth movement. Notice that the nondominant hand is used to extend the head. C,
The LMA is advanced until definite resistance is felt. D, Before the index finger is removed, the
nondominant hand presses down on the LMA to prevent dislodgment during removal of the index
finger. The cuff is subsequently inflated, and outward movement of the tube is often observed during
this inflation.
 Insertion of the
Combitube.
A.The tongue and mandible
are lifted with one hand,
and the Combitube is
inserted in the direction of
the natural curvature of the
pharynx with the other
hand. The printed ring is
aligned with the teeth. B,
The pharyngeal cuff is
inflated with 100 mL of air,
and the distal cuff is
inflated with 15 mL. C.
Ventilation is begun
through the longer no. 1
tube because placement is
usually in the esophagus.
D. If ventilation is absent
and the stomach is being
insufflated, begin
ventilation through the no.
2 connecting tube.
Fibreoptic Intubation
 Steps in emergency needle
cricothyroidotomy

• Extend the chin and neck to improve access

• Place syringe on needle/cannula.
• Identify CTM and stabilize larynx with one
hand.
• Insert needle through the CTM, aspirating
to confirm intratracheal location
• Once in the trachea keep needle still
• Slide cannula off inserted needle
• Remove needle only when cannula fully
inserted
• Aspirate free air through cannula to
confirm correct placement
• Secure the cannula with hand initially or
ties around neck later
• Apply short burst of high-pressure oxygen
• Watch chest rise appropriately and fall
• Maintain upper airway patency with
laryngeal mask or oral airway for exhalation
Retrograde Intubation
 Complications
1. During Laryngoscopy And Intubation.

2. While Tube is in place

3. Following Extubation
 During Laryngoscopy and Intubation
1. Malposition 3. Aspiration
Esophageal intubation
Endobronchial intubation 4. Physiological Reflexes
Hypertension,
2. Trauma Arrhythmia
Tooth damage Intracranial
Lip, Tongue, Mucosal Hypertension
laceration Intraocular
Dislocated Mandible Hypertension
Retropharyngeal dissection Bronchospasm
Cervical Spine Trauma
5. Tube Malfunction
Cuff perforation
 While Tube is in Place
● Malpositioning
– Unintentional Extubation
– Endobronchial Intubation
– Laryngeal cuff malposition

● Airway trauma
– Mucosal inflammation
– Excoriation of nose

● Tube malfunction
– Ignition
– Obstruction
 Following Extubation
● Airway trauma
– Edema, Stenosis
– Hoarseness / Sorethroat
– Laryngeal malfunction

● Physiologic reflexes

● Laryngospasm

● Aspiration