Airway managemnet

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Airway managemnet

• R1 ???

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ANATOMY
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Pharynx

• 1) Nasopharynx ? nasal cavity
• 2) Oropharynx ? oral cavity
• ? ????? palate? ?? ?? ????? ????? ???
• ? nasopharynx? oropharynx ? ????? soft
  palate ?? ???? ??? ??? ?? ??? ??
• 3) Laryngopharynx
• ? tongue base ?? ?? oropharynx ? epiglottis ?
  ?? ??
• 4) Epiglottis swallowing ?? ?? glottis ? ??
  aspiration ??

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Larynx

• 1) ? 9?? cartilages ? ??
• 2) ? ?? thyroid, cricoid, epigglotic cartilage
• 3) ? ?? arytenoid, corniculate, cuneiform
  cartilage

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Sensory supply of upper airway

• 1) Mucous membrane of nose Cranial n. V
  (trigeminal n.)
• ? ophthalmic div. V1 (ant. Ethmoidal n. )
  ant. part of nose
• ? maxillary div. V2 (sphenopaltine n.) post.
  part of nose
• 2) Soft and hard palate palatine n.
• 3) Tongue
• ? br. of mandibular div V3 (lingual n.) ant.
  2/3 ? general sensation
• ? IX (glossopharyngeal n.) post. 1/3 ?
  general sensation
• ? branch of VII ( facial n.) IX sensation
  of taste
• 4) Glossopharyngeal n (IX) ? ?? pharynx ? roof,
  tonsil soft palate ? under-surface ?? innervation

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Sensory supply of upper airway

• 5) Vagus n.(X) epiglottis ? ?? ??? airway ??
  sensation
• ? Sup. Laryngeal br. ext. br (motor) int. br
  (sensory)
• epiglottis ? vocal cord ?? ??? sensory
  supply
• ? Recurrent laryngeal n. vocal cord ???
  trachea ??
• sensory supply

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ANATOMY
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Motor supply of upper air way

• 1) Laryngeal m ?? ???? recurrent laryngeal n ?
  ?? ??
• ? ????? cricothyroid m. ? ext. laryngeal n ?
  ?? ??
• ? post. cricoarytenoid m abduction of vocal
  cord
• ? lat. cricoarytenoid m adduction of vocal
  cord

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Laryngeal n. injury ? ?? ??

• ?(?? motor n ??? ??)
• 1) Sup. laryngeal n. (ext. laryngeal n.? motor n.
  ? cricothyroid m)
• ? unilat. minimal effect
• ? bilat. hoaresness, tiring of voice (but
  airway effect? ??)
• 2) Recurrent laryngeal n.
• ? unilat. ipsilat. Vocal cord paralysis
  (voice quality ? ??)
• ? bilat . acute ? ??? ?? stridor,
  respiratory distress
• chronic ? ??? ?? aphonia
  
• 3) Vagus n.
• ? unilat. hoarseness
• ? bilat. aphonia

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Equipment
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Oral nasal airways

• 1) ??? upper airway muscle tone ? ??? ?? (eg.
  Genioglossus m) tongue? epiglottis ? post wall of
  pharynx ? ???? ??
• 2) ??? Repositioning ? jaw thrust ? prefered
  technique
• 3) Artificial airway ????? mouth ? nose ?, ??
  post. pharyngeal ??? airway passage ??

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Oral nasal airways

• 4) Laryngeal reflex ? intact ? ?? awake ? ?? ???
  ?? ??? ?? ?? airway insertion ?? cough,
  laryngospasm ?? ????
• 5) Adult oral airway size
• ? small 80mm(Guedel No.3), medium 90mm(Guedel
  No.4), large 100mm(Guedel No.5)
• 6) nasal airway? ??
• ? nares(??) ?? meatus of ear ??
• ? oral airway ? ??? ?? ? 2-4 cm ??
• 7) nasal airway ??
• ? anticoagulated patient, prominent adenoid ?
  ???, basilar skull Fx

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Face mask design technique

• Oxygen ?? anesthetic gas ? breathing system ??
  patient ? delivery ? ??? ??? air tight seal ? ??
• rim ??? ????? ? ?? ??orifice(22mm)attach
  breathing circuit through right-angle connector
• transparent mask allow observation of exhaled
  humidified gas and immediate recognition of
  vomiting

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Face mask design technique

• 7) Effective ventilation
• ? gas-tight mask fitting patent airway
• ? continued deflation of the bag !! leak
  around the mask
• ? High breathing-circuit pressure with minimal
  chest movement and breath sound !! obstructive
  airway
• 8) One hand face mask technique

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Face mask design technique

• 9) Two-handed technigue
• 10) Excessive downward pressure ? ?? Obx
• ?decreasing the pressure on the mask

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Face mask design technique

• 11) edentulous person
• ? gauze packing in buccal cavity may helpful
• 12) ????? mask ventilation? pressure injury ? br.
  of trigerminal n.? br. facial n ? ? ???.
• 13) Excessive pr. on eye and corneal inj. should
  be avoided

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Laryngeal mask design technique

• 1) Laryngeal mask airway(LMA)
• ?difficult airway ?? ???? TT? ventilation?
  passage??? ?
• ? fiberoptic bronchoscopy(FOB)? ventilation
  ????
• 2) ??
• ? proximal end ? 15mm ??? connector
• ? distal end ? ???? cuff ? ?? pilot tube ? ??
  inflation
• ? blind ?? hypopharynx? insertion ? inflation
• larynx ??? low pressure seal ??

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Laryngeal mask design technique

• 3) Ideally positioned cuff
• ?sup base of tongue
• ?lat. pyriform sinus
• ?inf upper esophageal sphincter
• 4) Down folding of epiglottis ? distal cuff ? M/C
  cause of failure
• ? laryngoscope ? fiberoptic bronchoscope ?
  ???? difficult case ?? ??? ? ???
• 5) LMA ? pharyngeal secretion ?? ?? larynx ?
  ????? ??
• ? ??? gastric secretion ? ?? ??
• ? airway reflex ? regained ? ? ?? LMA ? remain
  
• 6) CIx
• ?pharyngeal pathology(eg. Abscess), pharyngeal
  obx, full stomach(eg. Pregnancy, hiatal hernia),
  low pulmonary compliance(eg. Obesity) requiring
  peak inspiratory pr. greater than 20cmH2O

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Laryngeal mask design technique
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Esophageal-tracheal combitube design technique

• 1) ? ??? ??? tube?, ? ?? 15mm connector ??
• ? Longer blue tube distal tip ? ???? (exit
  gas through side perforations )
• ? Shorter clear tube open tip??, side
  perforations ??
• 2) ???? ???? shaft ? two black rings ? upper
  lower theeth ??? ???? ?? ??
• 3) ? ??cuff (prox 100cc, dist 15cc)
• 4) Distal lumen ? ?? esophagus? ?????(?95)
• ? ventilation? longer blue tube ? side
  perforation ? ?? larynx? ????
• ? shorter clear tube ? gastric decompression
  ??
• ? ?? tube ? trachea ? ???? clear tube ? ??
  trachea ? ??? ???

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Tracheal tube

• 1) TT ? anesthetic gas ? trachea ?? ????
• ? ventilation ? oxygenation ? ?? ??
• ? shape ? rigidity ?? ?? stylet ????
• ? patient end ? beveled ?? ?? vocal cord ? ??
  ???
• ? Murphy tube ? ?? hole ? ?? occlusion ??? ??

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Tracheal tube

• 2) Tube ? airflow ? ?? ??? ?? ??? ??? ??
• ? ? ?? ?? ? curvature ?? ?? ??
• 3) Cuff inflation system
• ? valve, pilot balloon, inflating tube, cuff
• 4) Positive pressure ventilation ? ????
  aspiration ??? ??
• ? children ? ?? pressure inj. ? ??? ??
  postintubation croup? ?? ?? cuff?? tube ??
• 5) Two types ? cuff
• -high pr.(low volume)?? ??? ?? ischemic damage
  ?? ??? intubation? ???
• -low pr.(high volume)sore throat?(?larger
  mucosal contact area), spontaneous extubation ?
  ??.

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Tracheal tube

• 6) Mucosal damage ? ?? low-pressure cuff?
  recommanded
• 7) Cuff pressure inflation vol.,?? ??, tracheal
  and cuff compliance, ? intrathoracic pr.?? ?? ???
  
• 8) Armored tube flexible, spiral-wound, wire
  reinforced tube
• ? kinking ? ???? ?? prone position?? HN
  surgery ? ?? ??? ??? ?? ?? ?? ?? ??? ???.

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Rigid laryngoscopes

• 1) Larynx ? ?? examine ? trachea ?? intubation ?
  ?? ??
• 2) Macintosh ? Miller balde ? ?? ?? ???

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Specialized laryngoscopes

• 1) ? 15? ??? difficult airway intubation ? ?? 2??
  ??? laryngoscope? ?? ?
• (A. Wu laryngoscope ? B.Bullard laryngoscope )
• 2) Fiberoptic light source ? ??? ???, large
  tounge patient? glottic openning ? ?? ??? ???
  ???? ?? glottic opening ? ? ? ? ? ??? ??

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Flexible fiberoptic bronchoscope

• ??? ??? ??(unstable c-spine, TM joint ? ROM ? ?
  ?? ?? ?)
• ? rigid laryngospopy ? ??? ?? ?? awake
  intubation ? ??? ?? ?? ???? ??
• 2) ??
• ? coated glass fiber (light image? ??)
• ? angulation wire
• ? aspiration channels (suctionning of
  secretion, oxygen insufflation, local anesthetics
  infection ? risk )

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Technique of direct laryngoscope intubation
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Indication for intubation

• 1) Aspiration ? ??? ?? ??
• 2) body cavity or HN surgical procedures
• LMA ? mask ventilation
• ? ?? ??? minor op ? ??
• ?) cystoscopy,???? examination,inguinal hernia
  op ?

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Preparation for rigid laryngoscopy

• 1) Equipment ?? ? ?? position
• 2) TT ? cuff inflation ??
• ? inflation ? syrynge ??? cuff? ???? ?? ??
• ? ?? ??? ??? bronchial intubation ??? ?? ??
  ??? ??? ?? TT ? ???? ?

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Preparation for rigid laryngoscopy

• 3) Stylet ???? hockey stick ???? ???? ??
• ? intubation ? ???? ???? ?? larynx ??? ??
• 4) Laryngoscope ? light ??
• 5) ?? ???? TT ? handle, blade ? ???? ????
• 6) Suction unit
• ? enexpected secretion ?? ??
• 7) Patient positioning
• ? ??? ?? ? ??? ??? ?? ? ??? ? ?? ??
• ???? back strain ??

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Preparation for rigid laryngoscopy

• 7) Laryngoscpy ? pharyngeal soft tissue? ??
• ? mouth ?? glottic openning ?? direct vision
  ??
• 8) Moderate head elevation(5-10cm), extension of
  atlantooccipital joint
• ? desired sniffing position

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Preparation for rigid laryngoscopy

• 9) Preoxygenation with several (four at total
  lung capacity)
• deep breaths of 100 Oygen
• ? ??? ?? ventilation ?? ??? safety? Extra
  margin? ??
• ? ??? Face mask? ?? ??? pulmonary dz? ???
  difficult intubation ? ?? ?? ??? ??
• 10) Induction ? ??? eye protection ? ??
• ? cornea abrasion ?? ?? (tape ? ???)
• General anesthesia ? ??? ??? ??? guardian !!

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Orotracheal intubation

• 1) Laryngoscope ? ???? ?? ????? ??? ?? ??? ?? ??
  ? blade? oropharynx ? Rt. Side? insertion
• ? ?? ????? ??
• 2) Tongue ? pharynx ? floor ??? ?? ???? ???
  insertion
• 3) Curved blade? ?? blade tip ? ?? vallecula ?
  insertion
• ? straight blade ? ?? tip ? epiglottis? ???
• 4) Handle ? raise up
• ? ??? mandible ? ??? ??? ?? ??? vocal cord ?
  expose ??? ??.

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Orotracheal intubation
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Orotracheal intubation

• 5) TT ? ????? ??? tip? abducted vocal cord? ????
  ?? ??
• ? TT cuff? upper trachea ? ?? ??? ?(but,
  larynx ??? ??)
• 6) ?? ??? ?? ?? laryngoscope? ??
• 7) Cuff ? ???? infaltion ? ??? ?
• ? positive pressure ventilation ? ??? ?? ???
  ???? ???? inflation
• ? tracheal mucosa? ???? ??? ??? ?
• ? pilot Balloon ? ?? ?? ????? ??? ??? ? ? ??
• 8) Intubation ? chest? epigastric area ? ??,
  capnogaphic tracing monitor ??? intratracheal
  location? ??

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Orotracheal intubation
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Orotracheal intubation

• 9) Capnography ?? CO2 detection
• ?TT? tracheal placement? ?? ?? ??
• ? bronchial intubation? r/o??? ??
• 10) Bronchial intubation ? ??? ??? peak
  inspiratory pressure??
• ? tube ? pilot balloon ? ??? sternal notch ???
  cuff ? ??? ?? ??
• 11) cuff ? cricoid cartilage ????? ?? ??? ??
• ? prolonged laryngeal location ? postop.
  hoarseness ? accidental extubation ? risk ????

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Orotracheal intubation

• 12) Oral intubation ? tolerance ? ?? ?? ??
  unconscious Pt ?? ??
• ? ?? awake Pt ?? ??? iv sedation ?? ?? ??,
  regional nerve block ?? Pt acceptance? ??? ?
• 13) ?? intubation ???,
• ? ??? repositioning
• ? tube size ??, stylet ??, ?? size? blade ??
• ? Nasal route ??
• ? ?? ??? ???? ?? ??
• ? mask ventilation? ??? ???? LMA, Combitube,
  cricothyrotomy ?? ?? ??? ????

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Nasotracheal intubation

• 1) ????? oral intubation? ??
• 2) Laryngoscopy? ?? ?? TT ? nose ? nasopharynx?
  ?? oropharynx ? ?? advance
• 3) nostril? ??? ?? ??? ??? ??
• 4) 0.5, 0.25 ? phenylephrine nose drop? ???
  ????? mucous membrane? shrink ??
• ? excessive use ? HTN, tachycardia ?? side
  effect
• ? awake pt ? ?? ?????? nerve block ? ??? ?
• 5) TT ? nose ? floor ? ?? ??
• ? inf. Turbinate ?? face? ??? ??? ??
• ? tube? bevel ? turbinate ?? ???? lat.side ?
  ??

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Nasotracheal intubation

• 6) TT? Proximal end ? pulled cephalad??
• 7) Oropharynx?? tube ? ??? ?? ????? advance
• 8) Laryngoscopy ? oral intubation? ???? ????
  vocal cord? ?? ???, tube? Trachea? advance
• ? ?? advance ? ???? Magill forcep ? ??
• ? ?? cuff ??? ??
• 9) Severe mid-facial trauma ?? nasotracheal
  intubation ?? L-tube ??? ??
• ? Intracranial placement????

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Techniques of extubation
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Techniques of extubation

• 1) TT??? ??? art of anesthesiology ? ? ? ?? ??
  ??? ??
• 2) Deeply anesthetized or awake anesthetized ??
  ??? ??
• 3) Neuromuscular blocking agent ??? ??? recover
  ???? ??
• ? Extubation ?? ??? ??
• 4) Light plane anesthesia ?? extubation? ??? ?
• ? laryngospasm ? ??? ??
• 5) Light anesthesia ? deep anesthesia? ??
• ? pharyngeal suction ? breath holding,
  coughing ?

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Techniques of extubation

• 6) Eye openning, purposeful movement ?? ??? awake
  ??
• 7) Awake ? extubation ? TT?? coughing ??
• ? HR, CVP, Arterial pressure, intracranial
  Pressure, intraocular pressure?? ??
• ? Wound dehiscence, bleeding ??
• 8) awake asthma Pt ? ?? TT ? ??? bronchospasm ?
  ?? trigger
• ?1.5mg/kg iv lidocaine ? suction ? extubation
  ?? ?? ?? ??
• ? ??? ?? deep anesthesia ?? extubation ? ? ??
• 9) Aspiration ?? TT removal ? airway control ?
  ??? ??? ???? ??
• ? deep anesthesia?? extubation ? CIx

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Techniques of extubation

• 10) Extubation ?? pharynx ?? suction
• ? aspiration ?? laryngospasm ? risk ? ??
• 11) TT ??? airway establish ? ??? ??
• ? 100 oxygen ?? ventilation
• 12) Extubation ?? TT? untie, untaped, cuff ?
  deflated
• 13) Extubation ?? ??? positive pressure ? ??
• ? cuff ??? ???? secretion ? pharynx ? blow up
• 14) TT ? extubation ? end expiration ?? end
  inspiration ??? ???? ??
• ? tube ? ??? smooth ? ???? remove
• 15) Face mask ? ?? extubation ? 100 oxygen ??
• ? RR ? ??? ??? ?? ??? ??? ??

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Complication of laryngoscopy intubation
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Complication of laryngoscopy intubation

• Hypoxia, hypercarbia, dental airway
  trauma, tube malpositionning, physiologic
  responses to airway instrument

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Airway trauma

• 1) Tooth damage
• ? M/C cause of malpractice
• 2) Sore throat to trachea stenosis
• 3) Prolonged external pressure on sensitive
  airway structure
• ? Pressure ? capillary-arteriolar blood
  pressure ? ????(? 30mm Hg) tissue ischemia ??
• ? inflammation, ulceration, granulation,
  stenosis ??
• 4) ????? ?? ?? ?? minimal ? cuff ? pressure
• ? ?? 20 mmHg ? ?? ???
• ? ??? ? ??? ?? ???? cuff site??? ? 75 ?? ??

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Airway trauma

• 5) Postintubation croup
• ? glottic, laryngeal, tracheal edema ? ?? ??
• ? ???? ?? ??
• ? Steroid ? ?? ( dexamethasone 0.2 mg/kg ??
  12mg) controversial
• 6) Vocal cord paralysis
• ? cuff compression, ?? ?? trauma
• ? recurrent laryngeal n. ??
• ? hoarseness? aspiration ?? ??
• ? anatomical ? TT ??
• 7) Postoperative hoarseness
• ? ???? ??, ??, difficult intubation ? ?? ??
• ? ?? ??? tube ??? ?? ??
• 8) Repeated attempt at laryngoscopy (difficult
  intubation ?)
• ? periglottic edema, face mask ventilation?
  ??? ???

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Errors of tracheal tube positionning

• 1) Unintentional esophageal intubation
• ? ???? TT ? tip? vocal cord ?? ??
• ? careful auscultation of bilat. breath sound
  absence of epigastric gurgling
• ? capnography ? CO2 ?? ?? (most reliable)
• ? Chest x-ray, FOB?? ?? ??
• 2) Broncheal intubation
• ? Rt. Main stem br.? ?? ??
• ? overinsertion? ??
• ??? unilat. breath sound , unexpected
  hypoxia(pulse oxymetry ???? ????? ??? ???),??
  ???? sternal notch ??? TT cuff ??? ??? ??, bag ?
  compliance ? ???? ?? (?? peak inspiratory
  pressure)

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Errors of tracheal tube positionning

• 3) Inadequate insertion?
• ? laryngeal trauma thyroid cartilage ????
  cuff ???
• 4) Patient ? reposition ?? ?? tube placement ? ??
  ??
• ? neck extension ? tube carina?? ???? flexion
  ?? carina ? ??? ?? ??

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Physiologic responses to airway instrumentation

• 1) Laryngoscopy? tracheal intubation? protective
  airway reflex? ??
• ? HTN, tachycardia ??
• ? LMA ? hemodynamic change? ??
• ?laryngoscope ?? ? lidocaine? (1.5mg/kg) 1-2?
  ??, remifentanil (1.0 microgram/kg) 1??,
  alfentanil (10-20 microgram/kg) 2-3??, fentanyl
  (0.5-1.0 microgram) 4-5?? ??
• ? sodium nitroprusside, NTG, BB, CCB ?? ??
• ? ???? arrythmia (?? ventricular bigeminy)
  ?intubationt
• ? ??? ?? ?? ?? ? ? ??
• 2) Laryngospasm
• ? forceful involuntary spasm of the laryngeal
  m.
• ? Sup. Laryngeal n.? stimulation ? ??

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Physiologic responses to airway instrumentation

• 2) Laryngospasm
• ? pharyngeal secretion, extubation ? TT? ??
  larynx ??
• ? awake ? deep anesthesia ?? ???.
• ?TX positive pressure ventilation with mask
  bag (100 oxygen)
• iv lidocaine 1-1.5 mg/kg)
• ? persist hypoxia ? succinylcholine ???
  laryngeal m. relax. ?? controlled ventilation
  ???? ?
• ? ?? ??? ?? negative pressure pul. edema ?? ??

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Tracheal tube malfunction

• 1) Valve cuff ??? ??
• ?intubation?? ??
• 2) TT Obx
• ? tube ? kinking, foreign body aspiration
• Thick secretion? ?? ????

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Case discussion

• Evaluation management of a difficult airway
  17 year old girl present for emergency drainage
  of a submandibular abscess

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Preoperative evaluation of a patient with
difficult airway

• 1) Airway history patient head and neck exam.
• 2) Old anesthesia record review
• ? for previous problems in airway management
• 3) Facial deformity mask pitting ??? ??
• 4) Abnormal limitation of TM joint
• 5) Limited neck extension (lt35) nasal approach
  or FOB
• 6) Uvula visualization ????
• 7) Airway obstruction hypoxia ??

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Which intubation technique is indicated ?

• 1) ? case ? ?? mouth ? pus drainage ??? positive
  pressue ventilation ? ????
• ? ??? induction ?? air way ??
• 2) Submandibular abscess
• ? nasal approach ? ? ??
• ?abscess ??? ?? Rigid larygoscopy ? exclude
• 3) ? ???? ??? ????
• ? awake/nasal/FOB
• ? awake/nasal/blind
• 4) ?? ??? ????? emergency tracheostomy ? ???? ???
  ?? ??

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Blind nasotracheal intubation

• 1) Lubrication of TT with lidocaine jelly TT ?
  ??? ???? ??? ??? ??
• 2) ??? head? sniffing position
• 3) Nares ? ??? ???? TT ? tip ? ????
• ? ?? ??? ?? ???? air movement ? ?????
• ? ?? Capnogram monitoring
• 4) ??? TT? ????
• 5) TT ? ?? trache ? ?? ?? ????
• ? neck extension, head rotation ??
• 6) Laryngeal or cricoid pressure
• 7) Intubation is confirmed
• ? iv induction ??

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What nerve block could be helpful during awake
intubation?

• 1) Bilateral injection of 2ml local anesthetic
  into the base of palatoglossal arch.
• 2) Bilat. Sup. Laryngeal n blocks
  transtracheal block

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Why Is it necessary to be prepared for emergency
tracheotomy

• 1) Laryngospasm ? mask? ??? ????? ???? ??
• ? succinylcholine ?? spasm? ?? ? ???, ?? ????
  pharyngeal m. ? relaxation ?? ?? upper airway obx
  ? ???? ventilation? ??????
• ? ??? ??? tracheotomy ? ???