Intubation and Anatomy of the Airway And Anesthesia

Intubation and Anatomy of the Airway And Anesthesia apparatus • • Laith Sorour Ismaeel Qattam Mohamad jaber Sarah Awaisheh

Anatomy and Airway assessment By: Laith Sorour • Why we need to know the anatomy of Respiratory tract? • Parts of the tract? Which components? • Innervation? Nerve injuries • Airway assessment and 1 -2 -3 Rule

ANATOMY OF RESPIRATORY TRACT • Anatomically Respiratory tract is divided into upper and lower tract in relation to vocal cord. Upper: nose, mouth, pharynx, larynx, trachea, and mainstem bronchi. Lower: bronchioles , terminal bronchioles, Respiratory bronchioles , alveolar ducts, alveolar sacs, alveoli. • Or according to its function into conducting zone and respiratory zone. • Conducting zone : • Function: filter, warm and moisten air and conduct air to and from the respiratory zone • Respiratory zone : (p. s in RED) • Function : gas exchange • And there are two openings to the human airway: the nose, which leads to the nasopharynx, and the mouth, which leads to the oropharynx. These passages are separated anteriorly by the palate, but they join posteriorly in the pharynx.

Oral cavity

Pharynx The pharynx is a U-shaped fibromuscular structure that extends from the base of the skull to the cricoid cartilage at the entrance to the esophagus. It opens anteriorly into the nasal cavity, the mouth, the larynx, and the nasopharynx, oropharynx, and laryngopharynx, respectively. **The nasopharynx is separated from the oropharynx by an imaginary plane that extends posteriorly. **The oropharynx is separated from the laryngopharynx by epiglottis at the base of the tongue.

LARYNX **The larynx is a cartilaginous skeleton held together by ligaments and muscle, Located below the tongue and hyoid bone, between the great vessels of neck. • Level of C 4 -C 6 • 44 mm in males and 36 mm in females **The larynx is composed of nine cartilages: • Thyroid • Cricoid • Epiglottis • & (in pairs) arytenoid, corniculate, and cuneiform. ***The thyroid cartilage shields the conus elasticus, which forms the vocal cords.

• LARYNGEAL FOLDS • Vestibular fold • Vocal fold • glottis : gap between the vocal folds, the narrowest part of the larynx (Entrance)

EXTRINSIC MUSCLES OF LARYNX • • • Sternothyroid muscles depress the larynx. Omohyoid muscles depress the larynx. Sternohyoid muscles depress the larynx. Inferior constrictor muscles Thyrohyoid muscles elevates the larynx. Digastric elevates the larynx. Stylohyoid elevates the larynx. Mylohyoid elevates the larynx. Geniohyoid elevates the larynx. Hyoglossus elevates the larynx. Genioglossus elevates the larynx

INTRINSIC MUSCLES OF LARYNX

INNERVATION OF LARYNX • The vagus nerve (cranial nerve X) provides sensation to the airway below the epiglottis. • Above the vocal cords The superior laryngeal branch divides into an external (motor) nerve for the cricothyroid muscle and an internal (sensory) laryngeal nerve –damage to this nerve will abolish the cough reflex. • Below the vocal cords the recurrent laryngeal nerve which innervates all sensation & all Intrinsic muscles except the cricothyroid muscle. WHY? Before it gave different branches, how it differs?

Innervation above glottis • The sensory supply to the upper airway is derived from the cranial nerves. • The mucous membranes of the nose are innervated by the ophthalmic division (V 1) of the trigeminal nerve anteriorly (anterior ethmoidal nerve) and by the maxillary division (V 2) posteriorly (sphenopalatine nerves). • The palatine nerves provide sensory fibers from the trigeminal nerve (V 2) to the superior and inferior surfaces of the hard and soft palate. • The olfactory nerve (cranial nerve I) innervates the nasal mucosa to provide the sense of smell. • The lingual nerve (a branch of the mandibular division [V 3] of the trigeminal nerve) and the glossopharyngeal nerve (cranial nerve IX) provide general sensation to the anterior two-thirds and posterior one-third of the tongue, respectively. • Branches of the facial nerve (VII) and glossopharyngeal nerve provide the sensation of taste to those areas, respectively. • The glossopharyngeal nerve also innervates the roof of the pharynx, the tonsils, and the undersurface of the soft palate.

TRACHEA • A cartilaginous (Anteriorly) and membranous (Posteriorly) tube which Begins as a continuation of the larynx at the lower border of cricoid cartilage at the level of C 6, and terminates at the carina (the point at which the right and left mainstem bronchi divide ), at the level of T 5. • Adults – 10 -16 cm long and 2. 5 cm in diameter. • Infants – 4 -5 cm long and may be as small as 3 mm in diameter. • Kept patent by the presence of C-shaped cartilaginous rings.

AIRWAY ASSESSMENT • A preanesthetic airway assessment is mandatory before every anesthetic procedure. • The goal of evaluating a patient's airway is to identify any possible problems with maintaining, protecting, and providing a patent airway during anesthesia. • Several anatomical and functional maneuvers can be performed to estimate the difficulty of endotracheal intubation; successful ventilation (with or without intubation) must be achieved by the anesthetist if mortality and morbidity are to be avoided, Although the presence of these examination findings may not be particularly sensitive for detecting a difficult intubation, the absence of these findings is predictive for relative ease of intubation. Assessments in general must include: • HistroryPhysical examination in general (Face, teeth, neck, chest, deformities, Facial hair, Obesity, syndromatic? ). • Mouth opening: an incisor distance of 3 cm or greater is desirable in an adult. • Mallampati classification: a frequently performed test that examines the size of the tongue in relation to the oral cavity. The more the tongue obstructs the view of the pharyngeal structures, the more difficult intubation may be. • Thyromental distance: This is the distance between the mentum (chin) and the superior thyroid notch. A distance greater than 3 fingerbreadths is desirable. • Neck circumference: A neck circumference of greater than 43 cm (17 inches) is associated with difficulties in visualization of the glottic opening. • TMJ & neck movements. • BMI (>30 may be a problem) • Ultra sound examination, Ultrasound can be used as an adjunct to confirm ETT placement as well as to assist in identification of the cricothyroid membrane during emergent cricothyroidotomy.

1 -2 -3 Rule One of the tests to assess the airway for intubation, what do the numbers in the name mean? RULES: • 1. TMJ MOBILITY • 2. MOUTH OPENING • 3. THYROMENTAL DISTANCE

FIRST RULE : (TMJ) MOBILITY • To find any restriction in mobility of the Temporo. Mandibular Joint, how important is this? What pathologies restrict it? 1. Ask the patient to sit up with his head in the neutral position. 2. open his mouth as wide as possible. -The condyle should rotate forward freely such that the space created between the tragus of the ear and the mandibular condyle is approximately one fingerbreadth in width. TEMPOROMANDIBULAR JOINT

Near tragus

SECOND RULE : 2 TESTS Mouth Opening(insicor distance) and tongue protrusion 1. Ask the patient to open his mouth as wide as he can. The aperture of the patient's mouth should admit at least 2 fingers (3 cm) between his teeth, on the other hand, It will be difficult to insert the laryngoscope blade on less than 2 fingers. P. S don’t forget to look for any missing or dentally worked teeth (Caps, bridges …. Why? ) 2. Ask the patient to protrude his tongue maximally. The structures visualized should include: 1) 2) 3) 4) 5) 6) The pharyngeal arches. Uvula. Soft palate. Hard palate. Tonsillar beds. Posterior pharyngeal wall. In intubation we care only when the tongue and soft palate are seen. (Mallampati 3&4)

Mallampati classification: • Class I: The entire palatal arch, including the bilateral faucial pillars, is visible down to the bases of the pillars. • Class II: The upper part of the faucial pillars and most of the uvula are visible. • Class III: Only the soft and hard palates are visible. • Class IV: Only the hard palate is visible.

THIRD THE RULE : THYROMENTAL DISTANCE This is the distance between the mentum (chin) and the superior thyroid notch. A distance greater than 3 fingerbreadths is desirable, adults who have less than 3 fingerbreadths may have either an anterior larynx or a small mandible, which will make intubation difficult.

Laryngeal view. Difficult intubation will be discussed later

-Airway obstruction -Oropharynx airway -Nasopharynx airway By: - Ismaeel Qattam

-Airway obstruction : Loss of upper airway muscle tone (eg, weakness of the genioglossus muscle) in anesthetized patients allows the tongue(most common) and epiglottis to fall back against the posterior wall of the pharynx. In the unconscious state, the most common cause is the tongue falling back into hypopharynx.

• Excluding intubation, simple maneuvers to overcome upper airway obstruction in the unconscious supine patient , include : -Clearing the airway of any foreign material. -Using the chin left maneuver. (it lift the patient's tongue away from the back (of the throat and provide an adequate airway). -Using Jaw thrust maneuver. -Inserting an artificial airways: Oropharyngeal , Nasopharyngeal and Laryngeal Mask Airway

• Head tilt-chin lift Jaw thrust

Oropharyngeal airway: OPA or guedel : is a medical device called an airway adjunct used to maintain or open a patient's airway by preventing the tongue to go back over the pharynx. It's a curved plastic tube, flattened in cross-section and flanged at the oral end.

The guedel comes with many sizes suitable for all patients with mostly used sizes from 2 to 4, for small adults to very large adults, respectively. To choose the suitable size , an estimate of the size required is given by comparing the airway length with the distance between the patient’s incisor teeth and the angle of the jaw.

The guedel is then inserted into the person's mouth upside down. Once contact is made with the back of the throat, the airway is rotated 180 degrees, allowing for easy insertion, and assuring that the tongue is secured. The device is removed when the person regains swallow reflex and can protect their own airway, or it is substituted for an advanced airway. It is removed simply by pulling on it without rotation. Can facilitate ventilation during CPR (cardiopulmonary resuscitation) and for people with a large tongue.

Nasopharyngeal airway: Round, malleable plastic tubes, also known as an NPA or nasal trumpet (because of its flared end), or nose hose, is a type of airway adjunct, and it's a tube that is designed to be inserted into the nasal passageway to secure an open airway. The purpose of the flared end is to prevent the device from becoming lost inside the patient's nose.

Since it is made of flexible material, it is designed to be lubricated and then gently passed up the nostril and down into the pharynx. May be used on conscious victims since it is better tolerated because it generally does not stimulate the gag reflex.

Notes: Nasal airways are contraindicated in-patients with severe trauma to the head and/or face due to the possibility of direct intrusion into brain tissue. If an obstruction is encountered, do not force the airway as severe bleeding may be provoked.

Equipment of intubation Done by : Mohamad jaber

laryngoscope

laryngoscope : is an instrument used to examine the larynx and to facilitate intubation of the trachea. **The handle usually contains batteries to light a bulb on the blade tip or, alternately, to power a fiberoptic bundle that terminates at the tip of the blade. The blade : The Macintosh and Miller blades are the most popular. But also we have wisconsin **The choice of blade depends on personal preference and patient anatomy. **Because no blade is perfect for all situations, the clinician should become familiar and proficient with a variety of blade designs Macintosh : is designed so that the tip lies anterior to the epiglottis Miller : is favored for children and are designed to pass posterior to the epiglottis. **Incorrect usage can cause trauma to the front incisors

Both Miller and Macintosh laryngoscope blades are available in sizes 0 (neonatal) through 4 (large adult). The Miller blades are commonly used for infants. It is easier to visualize the glottis using these blades than the Macintosh blade in infants, due to the larger size of the epiglottis relative to that of the glottis Various maneuvers, such as the “sniffing” position and external movement of the larynx with cricoid pressure during direct laryngoscopy, are used to improve the view.

Video laryngoscope Video- or optically based laryngoscopes have either a video chip (DCI system, Glide. Scope, Mc. Grath, Airway) or a lens/mirror (Airtraq) at the tip of the intubation blade to transmit a view of the glottis to the operator

Endotracheal Tubes (ETTs)

Endotracheal intubation is employed both for the conduct of general anesthesia and to facilitate the ventilator management of the critically ill. ** Most of endotracheal tubes made of either rubber or PVC (polymerized vinyl chloride) , which is a plastic (soft) , to prevent irritation to the mucosa. **The patient end of the tube is beveled to aid visualization and insertion through the vocal cords. Murphy tubes have a hole (the Murphy eye) to decrease the risk of occlusion, should the distal tube opening abut the carina or trachea. **Most adult ETTs have a cuff inflation system consisting of a valve, pilot balloon, inflating tube, and cuff. The valve prevents air loss after cuff inflation. The pilot balloon provides a gross indication of cuff inflation ETT cuffs , creating a tracheal seal, permit positive-pressure ventilation and reduce the likelihood of aspiration. **Disadvantages : higher cost, potential tracheal injury by cuff pressure ,

Types of tubes 1 - cuffed tubes 2 - uncuffed tubes : often used in infants and young children; however, in recent years, cuffed pediatric tubes have been increasingly favored.

According to the type of the cuff: There are two types : There are two major types of cuffs: 1 -high pressure (low volume) High-pressure cuffs are associated with more ischemic damage to the tracheal mucosa and are less suitable for intubations of long duration. 2 - Low-pressure(High volume) cuffs may increase the likelihood of sore throat (larger mucosal contact area), aspiration, spontaneous extubation, and difficult insertion (because of the floppy cuff). Nonetheless, because of their lower incidence of mucosal damage, low-pressure cuffs are most frequently employed

Size of tube : Resistance to airflow depends primarily on tube diameter, but is also affected by tube length and curvature. ETT size is usually designated in millimeters of internal diameter, or, less commonly, in the French scale (external diameter in millimeters multiplied by 3). The choice of tube diameter is always a compromise between maximizing flow with a larger size and minimizing airway trauma with a smaller size. Female 6. 5 -7 male 7. 5 -8

Shape of tube 1 -Reinforced tubes with nylon or steel spiral in such cases , to prevent kinking 2 -RAE tubes are curved tubes , for difficult intubations (eg. childrens) 3 -Double-lumen tube to ventilate the lungs in thoracic surgery if necessary independently

Laryngeal Mask Airway (LMA) The laryngeal mask airway (LMA) is a supraglottic airway device. The LMA provides an alternative to ventilation through a face mask or an ETT ** A laryngeal mask airway (LMA) consists of a wide-bore tube whose proximal end connects to a breathing circuit with a standard 15 -mm connector, and whose distal end is attached to an elliptical cuff that can be inflated through a pilot tube. **The deflated cuff is lubricated and inserted blindly into the hypopharynx so that, once inflated, the cuff forms a low-pressure seal around the entrance to the larynx. ** This requires muscle relaxation slightly greater than that required for the insertion of an oral airway. ** If the esophagus lies within the rim of the cuff, gastric distention and regurgitation become possible. ** LMA partially protects the larynx from pharyngeal secretions (but not gastric regurgitation), and it should remain in place until the patient has regained airway reflexes. This is usually signaled by coughing and mouth opening on command.

Inserted via the mouth to cover the laryngeal inlet Sealed by inflatable cuff Provides reliable airway Less irritating to the patient

LMA size LMA is produced in a variety of sizes suitable for all patients, from neonates to adults, with sizes 3, 4 and 5 being the most commonly used in female and male adult.

The use of the laryngeal mask overcomes some of the problems of the previous techniques: 1 -It is not affected by the shape of the patient’s face or the absence of teeth. 2 -The anaesthetist is not required to hold it in position, avoiding fatigue and allowing any other problems to be dealt with. Sore throat is a common side effect following LMA use. Injuries to the lingual, hypoglossal, and recurrent laryngeal nerves have been reported. Correct device sizing, avoidance of cuff hyperinflation, adequate lubrication, and gentle movement of the jaw during placement may reduce the likelihood of such injuries

Advantages and disadvantages of the laryngeal mask airway compared with face mask ventilation or tracheal intubation

Tracheal intubation Sarah Awaisheh BAU

Defention • Intubation is a standard procedure that involves inserting a flexible plastic tube down a person's throat. This is a common procedure, carried out in operating rooms and emergency rooms around the world.

Cont. • The primary purposes of intubation include: 1) If you are in an emergency situation involving severe respiratory problems 2) If you are having general anesthesia during surgical procedure to receive oxygen anesthetic agent 3) removing blockages 4) When muscle relaxants are used to facilitate a surgery

Technique of Tracheal Intubation (5 Steps)

(1) Head position the neck flexed at the level of lower cervical spine (c 6 -c 7) and the head extended at the atlanto-occipital joint (c 1 -c 2) This is known as the “sniffing position” And you have to adjust pillow underneath the head to improve the extension and lift the shoulder

What is the purpose of this head position? • The combination of cervical flexion (C 5, C 6) of the neck with atlanto(C 1)-occipital extension result in the alignment of the axes of the pharynx , larynx and oral to allow proper visualization from mouth through glottis. Neck flexed Head extended

(2) Opening the patient’s mouth • Position of anesthesiologist is behind the patient’s head • Left hand for holding laryngoscope • Right hand for opening the mouth and insertion of tube

Cont. • The patient’s mouth is fully opened using the index/middle finger and thumb of the right hand. • Index/middle finger: depress the lower mandible • Thumb: pull the upper mandible • This serves to open the mouth, extends the AO joint, and protects the teeth and lips

3)Applying the laryngoscope • The laryngoscope cosists of a handle, lights and blade, helps guide the endotraheal tube to its proper position. • Using the blade the doctor will gently raise the epiglottis introduced into the mouth along the right side of the tongue, displacing it to the left. • The blade is advanced until the tip lies at the base of tongue. • Force is then applied in the direction in which the handle of the laryngoscope is pointing (forward and upward, 45° from horizontal line) “backward, upward, rightward, pressure” (BURP) • Don’t approach your face to the patient to allow the arms to exert traction on the laryngoscope rather than attempting to lift the laryngoscope with the wrist (use arm, not wrist)

Laryngeal visualization and grading during direct laryngoscopy Grade 1 full view of glottis Grade 2 only posterior extremity of the glottis is visible Grade 3 only the epiglottis is seen Grade 4 no epiglottis or glottis structure visible

(4) Insertion of the ETT through the vocal cords and removing the laryngoscope • Left hand controlling the laryngoscope blade while the right hand opens the mouth and then passes the ETT tip through the laryngeal inlet. • once the endotracheal tube is in the trachea, inflate the balloon surrounding the tube to make sure it remains snugly in place. • The tube is then held firmly and the laryngoscope is carefully removed. • Tape the tube to the corner of your mouth to prevent moving from its position, and connected to a T-piece, anesthesia breathing circuit, bag valve mask device, or a mechanical ventilator. • Tip of ETT should be located at the lower part of the trachea, at least 2 cm above carina,

(5) Check to see if the tube is properly positioned in the lower part of the trachea (immediate absolute proof) • Observing the tube passing through the vocal cords • Vaporation that passes through the tube • Co 2 monitor changes (indirect conformation) Inflate the lung with special bag and listen for breath sounds on both sides of the chest and epigastrium, if the end of the tube is too low, both lungs will not receive the same amount of air Look for chest expansion with positive pressure ventilation Last step you can use the fibro optic

6) CXR Xray sometimes is taken immediately after intubation to confirm the tube placement ( mostly done in the ICU not in general anesthesia)

Thank you.