AIRWAY MANAGEMENT Jutarat Luanpholcharoenchai Topic modules Anatomy of

AIRWAY MANAGEMENT Jutarat Luanpholcharoenchai

Topic modules Anatomy of airway � Evaluation of airway � Airway equipments � Intubation & ventilation techniques (-> W : Airway Management) �

Respiratory tract UPPER TRACT

Anatomy of larynx

Trachea& Lungs Trachea : Adult 12 -15 cm , Newborn 4 cm Right mainstem : larger, shorter and less angle Endobronchial intubation RUL atelectasis

Evaluation of airway � History � Physical examination

History � Disease & Underlying disease mass/ tumor obesity infection Congenital& variation trauma contracture

History � History of previous anesthesia general anesthesia history of difficult intubation

Physical examination � � Airway examination Airway investigation

Airway examination � � � � General contour Oral cavity Inter incisor distance Mallampati classification Thyromental distance Neck circumference Range of motion of neck

Mallampati classification Laryngoscopic view

Difficult intubation Suspected inter incisor < 3 cm TMD < 6 cm Mallampati class >3 neck circumference > 40 cm limited TM joint or neck AO axis movement �

Investigation X-ray Neck Chest CT

Airway Equipments Artificial airway devices : supraglottic airway & endotracheal tube � Anesthesia mask � Laryngoscope � etc……. . �

Artificial airway Endotracheal tube Orotracheal tube Nasotracheal tube Double lumen tube Semirigid tube : armored, anode tube RAE tube Supraglottic airway LMA (laryngeal mask airway) Laryngeal tube Oropharyngeal / nasopharyngeal airway

Endotracheal tube • Less mucosal damage • Sore throat • Aspiration • Spontaneous extubation More mucosal damage!

Endotracheal tube Nasotracheal tube Cuff RAE tube Uncuff Double lumen tube

Endotracheal tube sizes Age Internal diameter (mm. ) Length (cm. ) Full term child Child 3. 5 Age(yr)/4 +4 10 -12 Age(yr)/2 +12 Adult -Female -Male 7. 0 -7. 5 -8. 0 20 -22 21 -24

Supraglottic airway LMA LARYNGEAL TUBE

Oral airway: oropharyngeal airway Vomitting Gag reflex Airway obstruction!!!

Nasal airway : nasopharyngeal airway Too long enter esophagus Mucosal injury/bleeding Better tolerance

Anesthesia mask

Rigid laryngoscope Bulb Curve blade “Macintosh” Blade Electrical contact Handle Straight blade

Lever-Tip Laryngoscope Blade

Etc…. . stylet Self inflating bag

INTUBATION & VENTILATION TECHNIQUES

Indications for Definitive Airway Protection Ventilation 1. Unconscious 1. Apnea • Neuromuscular Paralysis • Unconscious 2. Severe Maxillofacial fracture 2. Inadequate Respiratory Effort • Tachypnea • Hypoxia or Hypercarbia 3. Risk for aspiration • Bleeding • Vomiting 3. Severe closed head injury with need for hyperventilation 4. Risk for obstruction • Neck hematoma • Laryngeal, tracheal injury/burn

Equipments for endotracheal intubation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Rigid laryngoscope Endotracheal tube Anesthesia mask Airway : oral, nasal Syringe 10 cc Stylet Suction Stethoscope Anesthesia machine, breathing system , self inflating bag Monitoring : pulse oximeter, capnograph Other : Plaster, lidocaine jelly

Techniques for routine intubation 1. 2. Preoxygenation with 100% oxygen Administration of induction agent � 3. 4. 5. 6. Loss of eyelash/verbal reflex Mask ventilation Administration of neuromuscular block Intubation Confirm ETT in trachea

Airway maneuvers Head-tilt chin-lift Jaw-thrust maneuver

Face mask ventilation One hand two hand the two-hand mask hold is most effective KEYS SUCCESS a patent airway an adequate mask seal proper ventilation

Sniff position 10 cm.

Intubation Techniques Valeculla

Complication of intubation During laryngoscope & intubation • Malpositioning : esophageal intubation • Airway trauma : injury to tongue, lip etc. • Physiological reflexs : hypoxia, HT, tachycardia, laryngospasm • Tube malfunction : cuff perforation While tube is in place • Malpositioning : bronchial intubation • Airway trauma : injury to mucosa • Tube malfunction : obstruction Following extubation • Airway trauma : hoarseness, edema/stenosis of subglottic, trachea • Negative pressure pulmonary edema • laryngospasm

QUESTIONS ?