AIRWAY MANAGEMENTF. Heru IrwantoDept. Anestesi-Reanimasi FK UNPAD-FK UNSRI

ANATOMYSuccessful intubation, ventilation, cricothyrotomy, and regional anesthesia of the larynx require detailed knowledge of airway anatomy.There are two openings to the human airway:- pars nasalis- pars oralis

Anatomy of the airway

Common indications for tracheal intubation

A. Provide patent airway. B. Protection from aspiration from gastric contents. C. Facilitate positive-pressure ventilation. D. Operative position other than supine. E. Operative site near or involving the upper airway. F. Airway maintenance by mask is difficult. G. Disease involving the upper airway. H. One-lung ventilation. I. Altered level of consciousness. J. Tracheobronchial toilet. K. Severe pulmonary or multisystem injury.

EQUIPMENT

STATICS S : scope -> stethoscope, laryngoscopeT : tubeA : airway equipmentT : tapeI : introducer , stylet, mandrainC: connectorS : suction

Rigid LaryngoscopesA laryngoscope is an instrument used to examine the larynx and to facilitate intubation of the trachea.The Macintosh and Miller blades are the most popular curved and straight designsThe choice of blade depends on personal preference and patient anatomy

A rigid laryngoscope

Tracheal TubesTTs can be used to deliver anesthetic gases directly into the trachea and allow the most control of ventilation and oxygenationTTs are most commonly made from polyvinyl chlorideThe patient end of the tube is beveled to aid visualization and insertion through the vocal cordsMurphy tubes have a hole (the Murphy eye) to decrease the risk of occlusion should the distal tube opening abut the carina or trachea

TTs have been modified for a variety of specialized applicationsFlexible, spiral-wound, wire-reinforced TTs resist kinking and may prove valuable in some head and neck surgical procedures or in the prone patient

Oral Tracheal Tube Size Guidelines

AgeInternal Diameter (mm)Cut Length (cm)Full-term infant3.512ChildAdultFemale6.5-7.024Male7.59.024

Airway EquipmentLoss of upper airway muscle tone in anesthetized patients allows the tongue and epiglottis to fall back against the posterior wall of the pharynx.Repositioning the head or a jaw thrust is the preferred technique for opening the airwayAn artificial airway can be inserted through the mouth or nose to create an air passage between the tongue and the posterior pharyngeal wall

Face Mask DesignThe use of a face mask can facilitate delivery of oxygen or of an anesthetic gas from a breathing system to a patient by creating an airtight seal with the patient's faceTransparent masks allow observation of exhaled humidified gas and immediate recognition of vomitingBlack rubber masks are pliable enough to adapt to uncommon facial structures

Effective ventilation requires both a gas-tight mask fit and a patent airwayThe mask is held against the face by downward pressure on the mask body exerted by the left thumb and index fingerThe middle and ring finger grasp the mandible to facilitate extension of the atlantooccipital jointThe little finger is placed under the angle of the jaw and used to thrust the jaw anteriorly, the most important maneuver to allow ventilation to the patient

TECHNIQUES OF DIRECT LARYNGOSCOPY & INTUBATIONIntubation is not a risk-free procedure, however, and not all patients receiving general anesthesia require itSuccessful intubation often depends on correct patient positioningModerate head elevation (510 cm above the surgical table) and extension of the atlantooccipital joint place the patient in the desired sniffing position

Orotracheal IntubationThe laryngoscope is held in the left handWith the patient's mouth opened widely, the blade is introduced into theright side of the oropharynxThe tongue is swept to the left and up into the floor of the pharynx by the blade's flangeThe TT is taken with the right hand, and its tip is passed through the abducted vocal cords

After intubation, the chest and epigastrium are immediately auscultatedIf there is doubt about whether the tube is in the esophagus or trachea, it is prudent to remove the tube and ventilate the patient with a mask

Difficult AirwayOther clues to a potentially difficult laryngoscopy include : limited neck extension (< 35)a distance between the tip of the patient's mandible and hyoid bone of less than 7cma sternomental distance of less than 12.5 cm with the head fully extended and the mouth closeda poorly visualized uvula during voluntary tongue protrusion (Mallampati classification)

Complications of IntubationDuring laryngoscopy and intubationMalpositioningEsophageal intubationBronchial intubationAirway trauma - Dental damage- Lip, tongue, or mucosal laceration- Sore throat - Dislocated mandiblePhysiological reflexesHypoxia, hypercarbiaHypertension, tachycardiaIntracranial hypertension ,Intraocular hypertensionLaryngospasm

Complications of IntubationWhile the tube is in placeMalpositioningUnintentional extubation, Bronchial intubation,Laryngeal cuff positionAirway traumaMucosal inflammation and ulcerationFollowing extubationAirway traumaEdema and stenosis Hoarseness (vocal cord granuloma or paralysis)Laryngeal malfunction and aspirationLaryngospasm