Airway Management

1
(No Transcript)
2
(No Transcript)
3
(No Transcript)
4

• The patient who is difficult to ventilate and
  difficult to intubate is quite possibly the most
  serious problem faced by anesthesiologists
  because hypoxic brain injuries and cardiac arrest
  are real possibilities in this scenario.
• Although a thorough history and physical
  examination are likely to identify the majority
  of patients with difficult airway, unanticipated
  problems occasionally present.

5

• Only through preplanning and practiced algorithms
  are such situations managed optimally.
• The American Society of Anesthiologists has
  prepared a difficult airway algorithm to assist
  the clinician.
• Remember !!! This is not the time of heroism, if
  intubation or ventilation is difficult call for
  help.

6
How you can detect or expect difficult intubation?
7

• HISTORY
• Any Adverse events related to previous airway
  management episodes. For instance-
• Have they ever been informed by anesthesiologists
  that they had an airway management problem( i.e.
  difficult to intubate, difficult to ventilate ).
• Have they had a tracheostomy or other surgery or
  radiation about the face and neck ?
• Have they sustained significant burns to these
  areas ?
• Do they have obstructive sleep apnea or
  temporomandibular joint ( TMJ ) dysfunction ?
• Review of prior anesthetic records is helpful.

8

• Physical Examination-
• 1- Oral Cavity-
• Note extent and symmetry of opening ( three
  finger-breads is optimal ).
• The health of the teeth ( loose, missing, or
  cracked teeth should be documented ), and the
  presence of dental appliances.
• Prominent buck teeth may interfere with the use
  of a laryngoscope.
• The size of the tongue is noted ( large tongues
  rarely make airway management impossible, only
  more difficult ).
• High arched palates have been associated with
  difficulty in visualizing the larynx.

9

• 2- The mandible and the quality of TMJ function-
• A short mandibular body ( three finger breads )
  as measured from the mental process to the
  prominence of the thyroid cartilage ( thyromental
  distance ) suggests difficulty in visualizing the
  larynx.
• Patients with TMJ dysfunction may have asymmetry
  or limitations in opening the mouth as well as
  popping and clicking.
• Curiously some patients with TMJ dysfunction
  have greater difficulty with opening the mouth
  after anesthetic induction and neuromuscular
  paralysis than when they are awake and
  cooperative.

10

• 3- Examination of the neck-
• Evidence of prior surgeries ( especially
  tracheostomy ), or significant burn is noted.
• Evidence of any abnormal masses ( e.g. hematoma,
  abscess or cellulitis, lymphadenopathy, goitre,
  tumour, soft tissue swelling ) or tracheal
  deviation.
• A short or thick neck may prove problematic.
• The range of motion of the head and neck (
  laryngoscopy requires extension of the neck to
  facilitate visualization ).
• Elderly patients and patients with cervical
  fusions may have limited motion.
• Patients with cervical spine disease (disc or
  cervical instability as in rheomatoid arthritis )
  may develop neurologic symptoms with motion of
  the neck
• X-ray of the neck in flexion and extension may
  reveal cervical instability.
• In patients with laryngeal cancer, it is valuable
  to know the results of nasolaryngoscopy performed
  by otolaryngologist.

11

• 4- Misselaneous-
• Obesity may make the use of laryngoscopy
  difficult.
• Large breasts as in pregnant ladies also may make
  the use of laryngoscopy more difficlt.

12

• 5- Mallampati classification-

13
(No Transcript)
14

• Instruments available to facilitate airway
  management

15

• 1- Oxygen Supplementation-
• Devices used for oxygen supplementation range
  from nasal cannulas, face masks to masks with
  reservoirs and masks that can be used to deliver
  positive pressure ventilation.
• 2- Oral Airways-
• Usually constructed of hard plastic, available in
  numerous sizes, and shaped to curve behind the
  tongue lifting it of the posterior pharynx.
• It is importance cannot be overstated, because
  the tongue is the most frequent cause of airway
  obstruction.
• 3- Nasal Airways-
• Can be gently inserted down the nasal passages,
  and are better tolerated than oral airways in
  awake and or lightly anesthetized patients.

16
(No Transcript)
17

• 4- Laryngoscopes-
• Usually left handed, designed to facilitate
  visualization of the larynx.
• Short blades work best for obese patients or
  those with large breasts.
• Laryngoscope blades come in various styles and
  sizes.
• The commonest used blades include the curved
  Macintosh and the straight Miller blades.
• 5- Endotracheal tubes-
• It come in multitude of sizes and shapes, and
  they are commonly manufactured from polyvinyl
  chloride, with a radiopaque line from top to
  bottom.
• Internal diameter ranges from 2.0 to 10.0 mm in
  half-millimeter increments.
• ETT may be reinforced with wire.

18

• 6- Laryngeal Mask Airways-
• LMAs maintain a patient airway during anesthesia
  when ETT is neither required nor desired (e.g.
  asthmatic patients ).
• They are an important part of the management of
  difficult airways and patients can be intubated
  through a well-placed LMA.

19

• 7- Esophageal-Tracheal combitube-
• It is usually inserted blindly through the mouth
  and advanced until the black rings on the shaft
  lie between the upper and lower teeth.
• It provides better seal and better protection
  against gastric regurgitation and aspiration in
  comparison to LMA.

20
(No Transcript)