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AIRWAY MANAGEMENT
Airway Management
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To make sure the airway remains open
The most important action for the
resuscitation is immediately to clear
the respiratory tract by doing the Triple
Airway Maneuver (head looked up,
jaw pushed forward, mouth open)

Basic Techniques to Open
Airway
1. Head tilt
2. Chin Lift
3. Jaw Thrust
Trias
manouvers
Head Tilt Chin Lift
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Jaw Thrust
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Anatomy
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Airway Management
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1.Types of artificial airways
2. Indications
3. Complications
4. Placement
1. Types of Artificial Airways
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Pharyngeal
Endotracheal Tubes
Tracheostomy
Tubes
Laryngeal Masks
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Pharyngeal Airways
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Indications
Prevent obstruction from tongue in
unconscious patient
Facilitate suctioning
Facilitate mask/bag ventilation
Complications
May stimulate gag reflex in conscious or semi-
conscious patient
Vomiting and aspiration
Oral or nasal pharyngeal airways
Oral Pharyngeal Airways
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Types
Berman
Guedel
Placement
Cross-finger technique
Horizontal then turn down
Correct size - estimate from lips to
earlobe or angle of jaw
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Guedel
Berman
Nasopharyngeal
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nasal Trumpet
Indicated when oral
airway not feasible
Lock jaw
Fractured mandible
Pt conscious
Facilitates frequent
nasotracheal suctioning
(NTS)
Placement - lubricant
Hazards
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Nasopharyngeal Airways
Trumpets
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Combitube
100 ml
15 ml
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Esophageal Obturator Airway
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If tip of tube in esophagus
If no breath sounds, connect bag to clear tube
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Old combitube
No longer used
Endotracheal Tubes (ETT)
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Tube inserted through nose or mouth
Between vocal cords
Into trachea
Tip of tube 2 inches above carina
Indications ETT
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Airway of choice during CPR
Cuff inflated in trachea protects lower airway
and maintains a seal for ventilation
Facilitates suctioning of lower airway
Types of Endotracheal tubes
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Single lumen
Double lumen (Carlens tube)
Cole tube
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Cole
Fome
Lanz
Shiley
Rusch
Portex
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Double Lumen Tubes
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ET Tube markings
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Brand name
ID and OD
Z-79 - ANSI Committee for Review of
Anesthesia Equipment
IT - Implantation Tested
Murphy eye
Radiopague line
Length in cm
Tube sizes
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Adult male
34 - 36 French or 8.0 - 8.5 mm ID
(mm ID x 4) + 2 = French
Usually no cuff on tubes < 6.5 mm
Adult female
32 - 34 French or 7.5 - 8.0 mm ID
Pediatric sizes (> 2 y.o.)
4.5 + (Age/4)
Pediatric sizes (< 2 y.o.)
As large as childs little finger
Estimating Tube Size (ID)
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ID = (Age + 16) / 4
ID = Height (cm) / 20
Estimating Tube Length (cm )
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Oral: 12 + (Age / 2)
Nasal: 15 + (Age / 2)
Distances
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Teeth - cords adult - 12 - 15 cm
Teeth - carina approximately 27 cm
Trachea - 11 - 13 cm
Adult trachea diameter 1.5 - 2.5 cm
Infant trachea diameter 4 mm
Average depth of ETT insertion:
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23 cm from the teeth
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~ 1.5 inches
or 3.81 cm
1 in =
2.54 cm
Hi-Low Evac ETT
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Fig 6-50, p 183 Cairo & Pilbeam
Intubation
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Larynx is visualized and the endotracheal tube
is placed through the glottis.
Want to actually visualize the cuff passing
through the glottis.
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Straight or Miller blade lifts
epiglottis
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sniffing
position
Curved or Macintosh blade tip placed
at vallecula (area just above epiglottis)
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Laryngoscopic view
Grade II or III requiring multiple intubation attempts relatively
common ( 1 - 18%).
Grade III or IV with unsuccessful intubation rare (.05 - .35%)
Cannot ventilate by mask or intubate -> transtracheal jet
ventilation, tracheostomy (.0001 - .02%).
From Benumof, J. L. (1991) Management of the difficult adult airway.
Anesthesiology 74, 1087-1110.
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Relative tongue/pharyngeal size airway view
If patient in class I airway view then laryngoscopic view
is grade I 99-100% of the time. If class IV airway view then
laryngoscopic view is grade III or IV 100% of the time.
From Benumof, J. L. (1991) Management of the difficult adult airway.
Anesthesiology 74, 1087-1110.
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Grade 1 = no appreciable reduction of extension
Grade 2 = approximately 1/3 reduction
Grade 3 = approximately 2/3 reduction
Grade 4 = no appreciable extension
From Benumof, J. L. (1991) Management of the difficult adult airway.
Anesthesiology 74, 1087-1110.
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o
normal
Atlanto-occipital joint extension
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Tongue /
Pharyngeal
size

Neck
Exten
4 3 2 1
1 D A A A
2 E B B A
3 E C B B
4 E D C B
A = Likelihood of Difficulty negligible < 1%
B = LOD 1 - 5%
C = LOD possibly 20%
D = LOD likely 50%
E = LOD highly probable 95%
Nasal Intubation
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Spray 2% lidocaine
and 0.25%
Neosynephrine in
nose
Do blind intubation
or
Use Magill forceps
to guide tube into
place
Use smaller ID tube
Average distance
from mid-trachea to
naris is 25 cm
p 142 Principles of Airway Management
Infant Intubation
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Place tip of either straight or curved blade at
the vallecula.
Do not try and lift epiglottis with straight blade.
Types of Cuffs
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Low Pressure - High Volume
High Pressure - Low Volume (old)
Fome Cuff - Ambient pressure (do not inflate)
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Cuff
Pressure
Cuff pressure < 20 cm H
2
O ( 15 torr)
Cuff pressure > 5 torr blocks lymphatic
drainage
Cuff pressure > 18 blocks venous drainage
Cuff pressure > 30 blocks arterial flow
Shapiro, p 273
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Disadvantages ETT
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By-passes upper airway
100% RH at 32 - 34o C
May be trauma during insertion
Patient cannot talk
Numerous complications
Complications of ETT
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During intubation
While tube in place
During extubation
After extubation
Complications During
Intubation 49
Trauma
Right mainstem intubation
Esophageal intubation
Easy Cap CO
2
detectors turns yellow with
CO
2
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Right mainstem intubation
Complications While Tube in
Place
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Pressure necrosis
Mucosal edema
Laryngeal/tracheal granulomas
Tracheoesophageal fistula
Dislocated tube
Problems with cuff
Patient Disconnection from tube
Nosocomial infection
Tube Changer
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Insert in ET tube to change
Note cm at teeth
Slip old tube off keeping changer in place
Slip new tube on changer down to the same
level
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Complications During
Extubation
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Laryngeal spasm
Vocal cord trauma

Treat by applying slight positive pressure via
mask and bag until anesthesiology gets there
with succinylcholine, a rapid acting muscle
relaxant.
When Extubating
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Have oxygen ready (APN)
Have bag and mask ready
Have racemic epinephrine handy
Complications After Extubation
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Hoarseness temporary vocal cord injury (if lasts
> week granuloma formation*)
Glottic edema (adults) Inspiratory Stridor
Aerosolize racemic epinephrine (0.5 ml of 2.25%) and
steroid (1 mg of dexamethasone) in 4 ml NS
Will need to re-intubate if aerosol fails to reduce
swelling
Subglottic edema (infants) Inspiratory Stridor
because cricoid ring narrowest point along infant larynx
and trachea its exposed to > potential injury during
intubation
must re-intubate
Tracheal stenosis rarely occurs if cuff properly
inflated and maintained
* Shapiro, p 269
Face Mask
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Laryngeal Masks
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Positioned in the hypopharynx
Separates esophagus from trachea
Doesnt keep esophageal sphincter open
(EOA)
Doesnt keep glottis open (ETT)
Indications
Used instead of face masks for anesthesia
In cases of difficult intubation
Emergency cases waiting for intubation
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Laryngeal mask airway
LMA
CobraPLA perilaryngeal
airway
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Contra-indications for Laryngeal
Masks
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Full stomach
Hiatal hernia - protrusion of a portion of the
stomach up through the diaphragm - occurs in
about 40% pop --> Gastroesophageal reflux
Need for controlled ventilation
Placement
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Deflate cuff
Hyperextend neck
Insert mask parallel to palate
When esophageal sphincter is reached will
feel resistance
Inflate cuff
Black line must always be up
Mask must not rotate
Secure in place