Airway Management: from Pre-assessment to Intubation.

The perioperative concerns, skills and equipment needed for successful airway management and
adjunct introduction: a Student ODP’s perspective.
By Mr James A. Meachin
Correspondence e-mail: i9077274@bournemouth.ac.uk, jmeachin@live.co.uk

Introduction: non-invasive airway examination and

evaluation (Soliz et al, 2002), which can be
Airway management is a fundamental skill of particular benefit when dealing with pa-
in the implementation and maintenance of tients who have no anaesthetic history.
a general anaesthetic. Without manage-
ment, an anaesthetised patient will not nec- Although the Modified Mallampati Classifi-
essarily have full control over their airway, cation system (Fig. 1) should be used as a
giving the possibility of a partial obstruction, part of an airway assessment (Bair et al,
or other more serious complications, occur- 2008), studies have shown that a poor
ring (Griffiths, 1999). There are many ways view, described with Mallampati class III or
to reduce the risk of complications occur- IV, have an increased incidence of poor
ring in the anaesthetic room. These meth- laryngeal view (Mallampati et al, 1985, cited
ods can be subdivided into two main cate- in Bair et al, 2008), with the possibility of a
gories: prior preparation (Chethan et al, difficult intubation. So although not a defini-
2008) and pre-assessment (Neacsu, 2002). tive assessment the Mallampati provides a
reliable basis on which to judge an airway.
The aim of this discussion is to give the
perspective of a Student Operating Depart- There are several ways of conducting a
ment Practitioner on what systems are ob- “global” assessment of a patient’s airway,
served as being the most efficient and ef- some more invasive than others. Consider-
fective in the airway management of the ing that, for example, performing a direct
elective patient. This will comprise the se- laryngoscopy, fibreoptic bronchoscopy or
lection of equipment and choice of systems radiographic assessment (lateral cervical x-
to be used in the event of an unanticipated ray) (Gupta et al, 2005) may not be practi-
complication. Further considerations will cal prior to a surgical list, an “external” (or
non-invasive) system is most likely more
include suitability of different adjuncts (i.e.
ET or LMA) and what systems to use suitable. The L.E.M.O.N. system (Fig. 4)
should a patient have a difficult airway. examines a variety of physical attributes, Fig. 4
combined with a visual buccal investigation
“desaturation safety period” (Sirian, 2009;
Literature was selected from the Associa- (including the Modified Mallampati Classifi- Solis, 2008) during the induction process.
tion for Perioperative Practice Journal Ar- cation).
Pre-oxygenation serves to replace the ni-
chive, Bournemouth University E-Journals trogen in the lung’s “Functional Residual
database and a number of other profes- Pre-assessment can be made effective by Capacity” (FRC) with oxygen. The result is
sional organisations, with articles between utilising one assessment system, and
that a patient can tolerate apnoea for
1999 to 2010. Paediatric research has strictly adhering to it (Magboul, 2005). Giv- longer before critical hypoxia develops
been omitted, as it was not deemed rele- ing enough time to an in depth evaluation
vant to the subject area. will reduce that chance of complications, (Sirian, 2009). Following induction, as a
however it should be appreciated that in patient looses consciousness, the self pro-
some instances a difficult airway will remain tecting mechanisms of the airway become
undetected, and therefore pre-formulated non-functioning (Griffiths, 1999), and it is
Pre-assessment: plans must be practiced. the responsibility of the anaesthetist (or
sometimes anaesthetic practitioner) to
As there is no single method of providing a maintain that airway. There are two main
comprehensive assessment of a patients methods for manually preventing an uncon-
airway (Bair et al, 2008) and no system is Induction and Pre-Intubation: scious patient’s airway: the “head-tilt-chin-
considered 100% reliable (Neacsu, 2002) lift” (Fig. 2) and the “jaw thrust” (Fig. 3).
Therefore a variety of systems could be It is essential that before any attempted
used in order to create a full record of a anaesthetic induction, the anaesthetic prac- Both systems serve to open up the upper
patient. Information about the patient’s past titioner has obtained all the necessary (non-rigid) airway, whilst lifting the tongue
medical or surgical history or deformities equipment for airway management off the back of the throat, and thus prevent-
and abnormalities, along with any anaes- (Griffiths, 1999), and knowledge of the loca- ing obstruction. The next stage, particularly
thetic complications, that have been previ- tion and contents of a theatre departments during anaesthetic induction (rather than in
ously encountered are of supreme impor- difficult airway kit is essential. an emergency situation) is fitting an appro-
tance and should be noted during a pa- priately sized facemask, enabling ventila-
tient’s pre-surgery assessment. Part of the Pre-oxygenation is a simple procedure that tion through the anaesthetic circuit reser-
pre-assessment routine should be a basic, can provide a vital safety gap, or voir bag.

Fig. 1 Fig. 2 Fig. 3

1
(Continued from page 1)
Airway Adjuncts:
There are two classifications of airway ad-
junct, categorised as either “definitive” or
“non-definitive”.
In the initial stages of establishing an air-
way with an adjunct, two non-definitive
techniques can be employed. The naso-
pharyngeal (NPA) or oropharyngeal (OPA
or Guedel) airways are both useful but,
both have advantages and disadvantages.
The nasopharyngeal airway is more com-
monly used in the post-anaesthetic realm,
as it is “more tolerable” than an OPA; it is
less likely to trigger a patient’s gag reflex,
and therefore can be used on a conscious
or semi-conscious person.
The OPA (Fig. 5) can be found regularly in
use in the anaesthetic induction process, to
establish a patient’s airway when ventilating
prior to endotracheal intubation. It serves to
prevent the tongue from “flopping” back
(due to muscle relaxation) onto the epiglot-
tis and obstructing the airway and is used in
conjunction with an anaesthetic face mask.
A development from the OPA is the cuffed
oropharyngeal airway (COPA), which
serves the same function, but with the addi-
tion of an inflatable cuff and a 15mm port
connector, meaning that it can be used in
conjunction with an anaesthetic circuit as
an airway on a spontaneously breathing
patient (Soliz, 2002).
The laryngeal mask airway fills the gap
between face mask and endotracheal tubes
in terms of levels of invasiveness (Chethan
et al, 2008). There are several options
when considering LMA’s; however the
same pros and cons apply to most. Impor-
tantly the LMA device establishes an air-
way, allows spontaneous breathing or ven-
tilation up to 20cm H2O and eliminates the
need to manually maintain the airway
(Middleton, 2009).
Other advantages include removing the
need to paralyse the patient and speeding
up theatre turnover as the patient can be
transferred to the Post Anaesthesia Care
Unit with the adjunct still in situ. The most
significant disadvantage is that LMA de-
vices provide no, or at the least very little
(as is the case with the LMA Supreme)
protection from aspiration of gastric con-
tents (Middleton, 2009). This restricts their
usage to patients who are not at risk of
regurgitation.
Fig. 5
Fig. 6
Fig. 7 Fig. 8
Endo-tracheal intubation is the definitive
system for airway management, often de-
scribed as the “gold standard”, and is gen-
erally a necessity when ventilation required.
There is a lot of variation between anaes-
thetists as to which procedures intubation is
essential (for example, laparoscopic sur-
gery is now commonly performed with an
LMA Supreme as the adjunct), the following
list are usually indications (Griffiths, 1999):
 Emergency surgery (e.g. RSI)
 Difficult airways
 Abdominal/laparoscopic surgery
 Thoracic/cardiac surgery
 Most head, neck and neurological sur-
gery
After induction, an ETT (Fig. 6) will usually
be inserted into the trachea under direct
vision, using a laryngoscope, so that the
inflatable cuff is slightly below the vocal
cords. Once in place, the cuff should be
inflated so that any air leak is prevented
when subjected to positive pressure ventila-
tion (Chethan et al, 2008). ETT cuff pres-
sures should not be excessive
(hyperinflation), as this can cause irritation,
and in long term intubation, damage the
mucosal layer (Ganner, 2001), potentially
causing intra-tracheal pressure sores.
Fig. 9
2
Airway Equipment:
There are various items of accessory
equipment that are essential for any form of
airway management in the anaesthetic
room, excluding the aforementioned airway
adjuncts. Some will be integrated into the
anaesthetic room it self, others will be sin-
gle-patient-use items that will need replen-
ishing.
Beginning with integrated systems, the first
and most important is a reliable supply of
oxygen. This can be from a cylinder (so
long as levels are checked and replenished
regularly, Fig. 7) or from “piped” systems
integrated into the building. The next stage
is a method of de-pressurising (from
300bar/4351psi to ambient, Source: BOC
Healthcare, 2009) and delivering the oxy-
gen to the patient. The usual system for this
is through an anaesthetic machine, how-
ever alternatives include wall mounted flow-
meters (Fig. 8) or, as would be necessary
in an emergency, a self inflating bag, also
know as a Bag Valve Mask (BVM), or
“ambu-bag”.
Monitoring is the next fundamental area of
equipment. Monitoring should begin prior to
the anaesthetic and continue until the pa-
tient is discharged from hospital; however
the frequency of observations will vary from
constant in theatre to every few hours on
returning to the ward. The basic “numbers”
needed comprise Non-Invasive Blood Pres-
sure, Heart Rate, Oxygen Saturation and
capnography (Fig. 10), which detects ex-
haled CO2 (Chethan et al, 2008).
Fig. 10
Additional monitoring, which is usually ap-
propriate in more critical situations, include
Central Venus Pressure & Arterial Blood
pressure, oesophageal doppler ultrasono-
graphy measuring cardiac output and core
temperature, though most of these artefacts
are unlikely to be used in the anaesthetic
room.
The remaining items are of a more practical
nature, concerned with facilitating intuba-
tion, securing airways and field of view
management. Suction apparatus (Fig. 11)
Fig. 11
(Continued from page 2)
is vital during anaesthesia, firstly to improve
the field of view of whoever is intubating,
but crucially to prevent pulmonary aspira-
tion of stomach contents or mucosal secre-
tions.
The anaesthetic practitioner should have to
hand a syringe for LMA or ETT cuff infla-
tion, intubation aids (for example a gum-
elastic bougie or stylet) and methods of
securing any adjunct (tear-able tape or rib-
bon gauze ties). The final piece of equip-
ment should be a stethoscope, to listen for
even inflation on the patient’s lungs after
intubation, thus evaluating that the adjunct
in properly positioned (Bryden et al, 2000
and Chethan et al, 2008) .
The algorithm follows a logical sequence of 15).
interventions designed to prevent the pa-
tient suffering prolonged oxygen starvation, The Difficult Airway Society (2004) advise
each stage employing a different technique that either a cannula cricothyroidotomy or a
or action in an effort to oxygenate the pa- surgical cricothyroidotomy are only to be
tient. As previously mentioned, the first used in a life-threatening situation. A signifi-
action when an unanticipated difficult air- cant risk factor, of either type of cricothyroi-
way occurs is to get help. This will usually dotomy, is the potential to cause a trauma.
be (in the aforementioned situation) after Due to the proximity of the Superior Thyroid
direct laryngoscopy has taken place, and a Artery, found left and right laterally to the
difficult intubation has been recognised thyroid cartilage, there is a risk of arterio-
(DAS, 2004). puncture or damage to the posterior tra-
chea. It is also advised that a definitive air-
Remaining with an attempt on tracheal intu- way is established as soon as possible.
bation, the algorithm suggests using exter-
nal laryngeal manipulation, introducers
(such as gum-elastic bougies) or alternative
laryngoscopes, for example the McCoy
laryngoscope blade (Fig. 13).

Difficult Airway Procedure:

A patient with a difficult airway, if not al-
ready anticipated, is a situation where an
anaesthetist finds difficulty in mask ventila-
tion, tracheal intubation, of both (American
Society of Anaesthesiologists, Cited by
Soliz et al, 2002). One of the most useful
preparations that the anaesthetic practitio-
ner can perform is to have readily available
resuscitation equipment and alternative
airway equipment (Polansky, 1997), as safe
airway management can only be achieved
if the full range of adjuncts and devices are
available (Chethan et al, 2008).
If an unanticipated difficult airway situation
occurs, the first objective is to get help
(Bryden et al, 2000). It is accepted that
either shouting or using the emergency call
bell (that should be installed in the anaes-
thetic room) are acceptable forms of acquir-
ing help. The next stages should follow the
“Unanticipated difficult tracheal intubation”
algorithm set out by the Difficult Airway
Society, illustrated in Fig. 12 (there are
variations by the American Society of An-
aesthesiologists and the Association of
Anaesthetists of Great Britain and Ireland),
beginning with Plan A and using simple
systems of establishing intubation.
Fig. 13
Stage two of the algorithm advises estab-
lishing and airway using either an LMA or
an Intubating - LMA (or ILMA, Fig. 14). A
successful attempt, whereby ventilation and
oxygenation are confirmed, can then be
progressed to tracheal intubation via fibre-
optic scope, allowing visual confirmation of
the epiglottis, and therefore the vocal cords
(Peiris et al, 2008). If, following ILMA or
LMA insertion, tracheal intubation is not
achieved, the safest action is to postpone
the surgery and awaken the patient. With-
out an adequate airway, surgery should not
be continued as without an endotracheal
tube in place there is no protection from
lung aspiration and mechanical ventilation
is less effective (Soliz, 2002).
Should any attempt at ILMA or LMA inser-
tion prove unsuccessful, oxygenation is
essential and therefore non-depolarising
muscle relaxants should be reversed, and
face mask ventilation should continue in-
definitely until the patient regains con-
sciousness, with naso/oro-pharyngeal be- Similarly, knowledge of drugs that may be
ing used as appropriate.
The final intervention, should a “can’t intu- nium appropriately prepared for immediate
bate, can’t ventilate” situation develop, is use should laryngospasm occur.
the introduction of an artificial airway. In the
emergency situation, what is often referred
as an “emergency tracheotomy”, is infact a
chricothyroidotomy, whereby the mem-
brane between the base of the thyroid carti-
lage and the top of the cricoid cartilage is
punctured in order to bypass the larynx (Fig
Fig. 15
Conclusion:
Airway management is the fundamental
aspect of anaesthetic care; without effective
management of a patient’s airway, a surgi-
cal intervention can’t take place. The em-
phasis for the anaesthetic practitioner is on
pre-preparedness of skills and equipment.
With reference to equipment, it is the an-
aesthetic practitioner’s responsibility to
know the whereabouts of emergency equip-
ment, should an unexpected critical situa-
tion occur, and to have prepared the appro-
priate equipment for any expected difficul-
ties. To reiterate Chethan et al (2008) “It is
only with the full range of devices available
that safe airway management can be
achieved”, therefore if an anaesthetic prac-
titioner is unaware of where necessary (or
potentially necessary) equipment, they are
not able to properly care for their patient.
useful in an emergency situation is equally
as vital, for example having suxametho-
Pre-preparedness does not just stop with
the gathering of equipment; knowing what
to do and when is also vital for patient pro-
tection. A fundamental understanding of
emergency algorithms is essential for when
an unlikely situation transpires. For exam-
ple, being able to follow the Difficult Airway
Society’s algorithm for an Unanticipated
Difficult Tracheal Intubation when needed
could mean the difference between life and
death for a patient.

Full patient care can only be given if proce-

dures are followed and the location of all
potentially necessary equipment is known
and readily accessible.
Fig. 12 Fig. 14
3
References: Illustrative Acknowledgements:
Bair, A., Caravelli, R., Tyler, K., Laurin, ment: The Basics Of Endotracheal Intu- Figure 1: Venezuelan Society of Anaes-
E. (2008) Feasibility of the preoperative bation. The Internet Journal of Academic thesia, Venezuela (2007),www.mianeste
Mallampati airway assessment in emer- Physician Assistants, 1 (1). Available sia.com/03_profesionales/02_escalaAE
gency department patients. The Journal from: http://www.ispub.com/ostia/ REA.html
of Emergency Medicine, 38 (5): 677 – index.php?xmlPrinter=true&xmlFilePath
680. =journals/ijapa/vol1n1/airway4.xml Figure 2: Wales and West First Aid
[Accessed 18 October 2010] Training, UK (2010), www.walesandwest
BOC Healthcare (2009) Medical Gas -firstaid.co.uk/
Data Sheet: Medical Oxygen. BOC Sirian, R., Wills, J. (2009) Physiology of
Healthcare, Manchester, UK: BOC apnoea and the benefits of preoxygena- Figure 3: Boekje Pienter, Holland (2010),
Group Ltd. tion. British Journal of Anaesthesia, 9 www.boekje-pienter.nl/html/j.htm
(4): 105 – 108.
Bryden, D., Gwinnutt, C. (2000) Airway Figure 4: Internet Scientific Publications,
Management: the difficult airway. Solis, A., Baillard, C. (2008) Effective- USA (2010), www.ispub.com/ostia/
Trauma, 2 (2) 113 – 123. ness of preoxygenation using the head- index.php?xmlFilePath=journals/ija/
up position and non-invasive vantilation vol10n1/airway.xml
Chethan, D., Hughes, R. (2008) Tracheal to reduce hypoxaemia during inubation.
intubation, tracheal tubes and laryngeal Annales Franҫaises d-Anesthésie et de Figure 5: Asian Intensive Care Re-
mask airways. Journal of Perioperative Réanimation, 27 (6): 490 – 494. search, Chinese University of Hong
Practice, 18 (3): 88 – 94. Kong (2010), http://www.aic.cuhk.edu.hk
Soliz, J., Sinha, A., Thakar, D. (2002) /web8/Hi%20res/Guedel%20airway.jpg
Difficult Airway Society (2004) Unantici- Airway Management: A review and up-
pated difficult tracheal intubation during date. The Internet Journal of Anesthesi- Figure 6: My Respiratory Supply, USA
routine induction of anaesthesia in an ology, 6 (1). Available from: http:// (2007), www.myrespiratorysupply.com/
adult patient – Flow Chart. Difficult Air- www.ispub.com/journal/the_internet_ anesthesia-endotracheal-tube-c-
way Society, UK: Difficult Airway Society. journal_of_anesthesiology/volume_6 9_17.html
_number_1_28/article/air
Ganner, C. (2001) Specialist nursing: way_management_a_review_and_updat Figure 7: BOC Vital Air, UK (2010),
The accurate measurement of endotra- e.html [Accessed 23 September 2010] http://www.bocvitalair.co.uk/vitalair/clinici
cheal tube cuff pressures. British Journal ans/portablecylinders_clinicians.asp?tab
of Nursing, 10 (17): 1127 – 1134. no=3&tabid=sc3

Griffiths, R. (1999) Back to Basics, An- Figure 8: GE Healthcare, UK (2005),

aesthesia: Airway Management. British http://www.gehealthcare.com/euen/
Journal of Theatre Nursing, 9 (10): 480 – anesthesia/docs/Aespire7900_bro_M10
483. 44472_eng.pdf

Gupta, S., Sharma, R., Jain, D. (2005) Figure 9: VetQuip, USA (2007), http://
Airway Assessment: Predictors of Diffi- www.vetquip.com.au/search.asp?
cult Airway. Indian Journal of Anaesthe- search=Anaesthesia
sia, 49 (4): 257 – 262.
Figure 10: Shohomish County Paramed-
Magboul, M. (2005) The dilemma of air- ics Discussion Board, USA (2010),
way assessment and evaluation. The Acknowledgements: http://snohomishcountymedics.terapad.
Internet Journal of Anesthesiology, 10 com/
(1). Available from: http:// The author would like to thank family and
www.ispub.com/ostia/index.php? friends who contributed artistically to this Figure 11: Medicare Equipments, India
xmlFilePath=journals/ija/vol10n1/ work, and his academic tutors who (2010), http://www.medicare-india.com/
airway.xml [Accessed 28 September stimulated the thought processes behind aspirator_medi2000dx.htm
2010] this research.
Figure 12: Difficult Airway Society, UK
Middleton, P. (2009) Insertion techniques About the Author: (2004), http://www.das.uk.com/files/ddl-
of the laryngeal mask airway: A literature Jul04-A4.pdf
review. Journal of Perioperative Practice, James A. Meachin
19 (1): 31 – 35. BSc (Hons) (Ports) Figure 13: Koala Medical, Australia
(2009), http://www.koalamedical.com.au/
Neacsu, A. (2002) Prediction of difficult Currently completing products.php5?fibre_optic_difficult
intubation: a pre-assessment nurses’ the second year of a
guide. British Journal of Perioperative Diploma in Higher Figure 14: Airway Skills, Australia
Nursing, 12 (7): 249 – 253. Education in Operating (2006), http://www.airwayskills.com/
Department Practice, page.php?12
Peiris, K., Frerk, C. (2008) Awake intuba- through Bournemouth University School of
tion. Journal of Perioperative Practice, Health and Social Care , and is in practice Figure 15: Olek Remesz, USA (2009),
18 (3): 96 – 104. at Poole NHS Hospital Foundation Trust.
http://en.wikipedia.org/wiki/
Polansky, M. (1997) Airway Manage- File:Larynx_external_Cricothyrotomy.gif