AIRWAY MANAGEMENT establishing,

maintaining & removing artificial

airway with complications.

Dr. Poonam Patel

AIRWAY MANAGEMENT

1.
2.
3.
4.

Assessment Mallampati score, mouth opening,

thyromental distance
Securing & maintenance airway devices
Artificial airway
Supraglottic airway devices
Tracheal tube
Devices for difficult airway

Management of complications

AIRWAY ASSESSMENT

Cervical spine movement

T-M joint movement
Mouth opening
Modified Mallampati grading
Thyromental distance

ARTIFICIAL AIRWAY
Purpose of an airway lift the tongue and epiglottis away
from the posterior pharyngeal wall.
Advantage of an airway
Cervical spine movement does not occur when airway is
inserted.
Decreased work of breathing during spontaneous
respiration using a face mask.
Types

Oropharyngeal airway
Nasopharyngeal airway

AIRWAY ANATOMY

A. Normal

B. Obstructed airway

OROPHARYNGEAL AIRWAY
Guedel airway
Parts flange, bite portion, air channel

OROPHARYNGEAL AIRWAY (contd.)

Sizes available
Colour coding

Sizes

Length (mm)

000

30

00

40

50

60

70

80

90

100

110

OROPHARYNGEAL AIRWAYS (contd.)

1)
2)
3)
4)
5)
6)

1)
2)

Uses
To maintain open airway
Prevent endotracheal tube occlusion
Prevent tongue bite
Facilitate suction
Conduit for passing devices into oropharynx
Obtain a better mask fit
Contraindications
Intact gag reflex
Oropharyngeal growth

OROPHARYNGEAL AIRWAY (contd.)

Pre requisite for insertion
Size estimation
Methods of insertion
Disadvantages 1) Due to incorrect size
2) Laryngospasm in awake patient
Advantages 1) Simple to use, cheap.
2) Not associated with sore throat
3) Does not cause bacteremia

NASOPHARYNGEAL AIRWAY

Parts flange, airway channel, bevel.

Size - inside diameter in millimeters.
Size determination
Method of insertion

Contraindications
1) Anticoagulation
2) Basilar skull fracture
3) Nasal pathology, sepsis, or deformity of the nose or
nasopharynx
4) History of epistaxis requiring medical treatment.

NASOPHARYNGEAL AIRWAY (contd.)

1.
2.
3.
4.
5.
6.
7.

Uses of nasopharyngeal airway

To maintain airway in patients with intact gag reflex
To facilitate suctioning
As a guide for a fiberscope or nasogastric tube
To apply continuous positive airway pressure (CPAP)
To dilate the nasal passages in preparation for
nasotracheal intubation
To maintain the airway and administer anesthesia
during dental surgery.
To maintain ventilation during oral fiberoptic endoscopy.

NASOPHARYNGEAL AIRWAY (contd.)

Advantages1) Nasal airway is better tolerated than an oral airway if the
patient has intact airway reflexes.
2) Loose or poor dentition.
3) Trauma or pathology of the oral cavity.
4) It can be used when the mouth cannot be opened.

COMPLICATIONS OF ARTIFICIAL AIRWAY

1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)

Airway Obstruction
Trauma
Tissue Edema
Ulceration and Necrosis
Central Nervous System Trauma
Dental Damage
Laryngospasm and Coughing
Retention, Aspiration, or Swallowing
Devices Caught in Airway
Equipment Failure
Latex Allergy
Gastric Distention

SUPRAGLOTTIC AIRWAY DEVICES

Supraglottic devices fill a niche between the face mask
and tracheal tube in terms of both anatomical position
and degree of invasiveness.
These devices sit outside the trachea but provide a
handsfree means of achieving a gas-tight airway.

SUPRAGLOTTIC AIRWAY DEVICES

1)

Laryngeal Mask Airway Family

LMA Classic
LMA Unique
LMA Flexible
LMA Fastrach
LMA CTrach
LMA Proseal
2) Other supraglottic airways similar to laryngeal mask

Soft seal laryngeal mask

Ambu laryngeal mask

Intubating laryngeal airway

3) Other supraglottic airway devices

Laryngeal tube airway

Perilaryngeal airway

Streamlined pharynx airway liner

LARYNGEAL MASK AIRWAY FAMILY

LMA-Classic (standard LMA,

Classic LMA, LMA-C, cLMA)

1.
2.
3.
4.
5.
6.
7.

PARTS
Curved tube (shaft)
Elliptical spoon-shaped mask
Two flexible vertical bars.
An inflatable cuff.
An inflation tube
Self-sealing pilot balloon.
15-mm connector .

cLMA size

Patient size

Neonates/infants up to 5 kg

1.5

Infants between 5 and 10 kg

Infants/children between 10
and 20 kg

2.5

Children between 20 and 30 kg

Children 30 to 50 kg

Adults 50 to 70 kg

Adults 70 to 100 kg

Adults over 100 kg.

LMA CLASSIC

1.
2.
3.
4.

Insertion methods
Standard Technique
180-degree Technique
Partial Inflation Technique
Thumb Insertion Technique

LMA-UNIQUE
Disposable laryngeal mask airway, DLMA).
It is made of polyvinylchloride
The dimensions are identical to the standard LMA, the
tube is stiffer and the cuff less compliant.
Sizes
It may be a better choice for out-of-hospital or ward use.
Insertion and placement of the LMA-Unique is similar to
the LMA-Classic.
The intracuff pressure increases significantly less in the
LMA-Unique when nitrous oxide is used.

LMA-FLEXIBLE
The LMA-Flexible (wire-reinforced, reinforced LMA,
RLMA, FLMA, flexible LMA) has a flexible, wirereinforced tube.
The tube is longer and narrower.
Not available in sizes 1 and 1.5
Useful for head and neck surgeries
Insertion method
Disadvantages 1) The wire reinforcement does not prevent obstruction from
biting.
2) The spiral reinforcing wire may become disrupted.
3) Only small sizes of tracheal tube or bronchoscope can
pass through it.
4) Not preferred prolonged spontaneous ventilation.
5) Unsuitable for MRI scanning
6) Malposition is less easily diagnosed.

LMA-FASTRACH
The LMA-Fastrach (intubating
LMA, ILMA, ILM, intubating
laryngeal mask airway)
designed for tracheal
intubation.
Parts
1) A short, curved stainless steel
shaft with a standard 15-mm
connector.
2) Single, movable epiglottic
elevator bar
3) A V-shaped guiding ramp built
into the floor of the mask.

LMA-FASTRACH

Insertion technique

Uses
To facilitate tracheal intubation
It can also be used as a primary airway device.

1.
2.

1.
2.
3.
4.

Tracheal Intubation using LMA Fastrach

Blind,
Blind nasal
Fiberscopic guided
Light guided

LMA-FASTRACH
Disadvantages
1. Pharyngeal pathology or limited mouth opening may
make intubation difficult.
2. Cannot be used for intubation in patients below 30 kg.
3. The LMA-Fastrach tracheal tube is expensive &
prolonged use is to be avoided.
4. The tracheal tube may be displaced downward or
dislodged.
5. It should not be used in the prone position
6. Unsuitable for use in the MRI unit.
7. Increased incidence of sore throat and difficulty
swallowing .
8. In patients with immobilized cervical spine, exerts
pressure on the cervical spine.

LMA-CTrach
It has two built-in fiberoptic channels with a
monitor.
Sizes - 3, 4, and 5
Insertion technique
Advantages
1) High first intubation attempt success rate with
minimal neck movement.
2) Can be used during awake intubation in the
presence of an unstable cervical spine.
Disadvantages
1) Poor image quality
2) The view may be obstructed by secretions,
lubricant, or blood.
3) Cannot be used easily in the patient with a
limited mouth opening.

LMA-ProSeal
Parts - cuff, inflation line with pilot
balloon, airway tube, and drain
(gastric access) tube.
Function of second dorsal cuff
Insertion techniques introducer,
guided, digital methods
Confirmation of proper placement

LMA-ProSeal
LMA Size

Weight (kg)

Max Cuff
Inflation
Volume
(mL)

Max.
Fiberoptic
Scope Size
(mm)

Max.
Length
gastric of Drain
Tube
Tube
Size (Fr)
(cm)

Largest
Tracheal
Tube (ID
in mm)

1.5

5 to 10

10

18.2

4.0
uncuffed

10 to 20

10

10

19.0

4.0
uncuffed

2.5

20 to 30

14

14

23.0

4.5
uncuffed

30 to 50

20

16

26.5

5.0
uncuffed

50 to 70

30

16

27.5

5.0
uncuffed

70 to 100

40

18

28.5

6.0 cuffed

LMA-ProSeal
Uses
1) Can be used for both spontaneous and controlled
ventilation.
2) Preferred in situations where higher airway pressures
are required, better airway protection is desirable, and
for surgical procedures in which intraoperative gastric
drainage or decompression is needed
3) Useful in cases where it is important to avoid airway
trauma.
4) Safe for use in an MRI unit

LMA-ProSeal
Disadvantages 1) The LMA-ProSeal is less suitable as an intubation
device.
2) Higher resistance in spontaneously breathing patients
than other devices.
3) Requires a greater depth of anesthesia for insertion.
4) Airway obstruction after insertion.
5) Gastric insufflation
6) The LMA-ProSeal has a shorter life span.

LARYNGEAL TUBE AIRWAY

Parts
1) The airway tube is wide, curved, color
coded on the connector.
2) single lumen that is closed at the tip.
3) Small (esophageal, distal) cuff near the
blind distal tip
4) Large (oropharyngeal, pharyngeal) cuff
near the middle of the tube

LARYNGEAL TUBE AIRWAY (Cont.)

5) One inflation tube to inflate both light
blue cuffs.
6) Two anterior-facing, oval-shaped
openings (ventilation holes)
7) Side holes lateral to the top of the distal
opening.
8) A ramp leads from the posterior wall
toward the main ventilatory outlet
Reusable silicone or single-use
versions made of polyvinylchloride.

LARYNGEAL TUBE AIRWAY (Cont.)

Size

Patient

weight (kg)

Color of
Connector

Maximum
Cuff Volume
(mL)

neonate

<6

Transparent

15

infant

6 - 15

white

40

child

15 - 30

green

60

Small adult

30 - 60

yellow

120

Medium adult

50 90

red

130

Large adult

> 90

violet

150

LARYNGEAL TUBE AIRWAY (Cont.)

Insertion technique
Advantages 1) The LT is relatively easy to insert
2) It is well tolerated during emergence
3) Because the distal cuff fits over the esophageal inlet, the
risk of gastric inflation is low
4) Can be used with both spontaneous and controlled
ventilation
5) High ventilation pressures can be used.

Laryngeal Tube Airway (Cont.)

6) This device may be especially useful for resuscitation
(cannot intubate, cannot ventilate situation ,
obstetrics after failed intubation, edentulous patients).
7) The incidence of complications such as sore throat,
mouth pain, or dysphagia is low.
8) Regurgitated liquid is less likely to be aspirated with the
LT

1.

Disadvantage
Failure to ventilate if tube enters trachea contrast
combitube

ENDOTRACHEAL TUBE
The tracheal tube (endotracheal tube,
intratracheal tube, tracheal catheter)
is a device that is inserted through the
larynx into the trachea to convey
gases and vapors to and from the
lungs.
Parts
1) The machine (proximal) end
2) The patient (tracheal or distal) end
3) Bevel.

ENDOTRACHEAL TUBE
4) Murphy eye
5) A radiopaque marker
6) Cuff Systems - consists
of the cuff plus an
inflation system, which
includes an inflation tube,
a pilot balloon, and an
inflation valve.

ENDOTRACHEAL TUBE
Latex coated red rubber tubes

PVC tubes

Reused multiple times

Disposable

Not transparent

Transparent

Harden and become sticky with

age, poor resistance to kinking,
become clogged by dried
secretions

Less likely to kink than rubber

tubes. They are stiff enough for
intubation at room temperature but
soften at body temperature, so
they tend to conform to the
patient's upper airway.

Latex allergy in susceptible

patients

No latex allergy

ENDOTRACHEAL TUBE
Oral intubation
1. Direct Laryngoscopy
2. Blind Oral Intubation
3. Digital Technique
4. Fiberoptic guided
5. Retrograde intubation
Nasal intubation
1. Direct Laryngoscopy
2. Flexible Fiberoptic Laryngoscopy
3. Blind Nasal Intubation

EXTUBATION
The tracheal tube (extubation) is removed when it is no
longer needed for airway protection.
Extubation may be performed at different depths of
anesthesia - awake, light, and deep
Preparation for Extubation
1. Initial Plan
2. Patient position plan
3. Bite block in place
4. Throat pack removed
5. Preoxygenation
6. Secretions aspirated from the pharynx (the trachea also
if indicated)

EXTUBATION
Complications at Extubation
1. Hypoventilation (residual effect of anesthetic drugs and
neuromuscular blockade)
2. Upper airway obstruction
3. Laryngospasm and bronchospasm
4. Coughing (wound disruption)
5. Impaired laryngeal competence and pulmonary
aspiration
6. Hypertension, tachycardia, dysrhythmias, myocardial
ischemia

FLEXIBLE FIBEROPTIC BRONCHOSCOPY

Indications
1. Difficult intubation predicted
2. Congenital airway abnormalities
3. Acquired airway abnormalities
4. Trauma
Contraindications1. Lack of time
2. Blood & secretions in oral cavity
3. Edema of pharynx or tongue

Technique oral or nasal (awake or GA)

COMBITUBE
Device for difficult airway
PARTS
1) Two separate lumens (pharyngeal & tracheoesophageal)
that are fused longitudinally
2) Two inflatable cuffs.
3) Each lumen is linked by a short tube to a standard 15mm connector at the breathing system end.
4) Pharyngeal lumen - occluded distal end and eight ovalshaped perforations (ventilating eyes) between the cuffs,
coloured blue.

COMBITUBE
5) Tracheoesophageal lumen patent distal end and a clear
tube.
6) The smaller distal cuff serves
to seal either the esophagus or
trachea, depending on its
placement.
7) The larger (pharyngeal) cuff
(balloon) is above the
perforations.
8) The pilot balloon for the
pharyngeal cuff is colored blue.

COMBITUBE

Sizes:
1. Regular (41 [Fr])
2. SA (37 Fr)

Recommended for patients with a height greater than 5

feet (152 cm).
Not recommended for patients younger than 12 years of
age.
METHOD OF INSERTION

COMBITUBE

Indications

1.
2.
3.
4.
5.

Airway management in the difficult-to-intubate patient

Massive airway bleeding or regurgitation.
Limited access to the airway and limited mouth opening
Cervical spine injury.
Useful in entertainers in whom it is important to avoid
vocal cord damage.
In cardiopulmonary resuscitation in both prehospital
and in-hospital settings.
Cannot ventilate, cannot intubate situation.
Can be used during percutaneous dilatational
tracheostomy or tracheotomy

6.
7.
8.

COMBITUBE

Contraindications
1. Active pharyngeal or laryngeal reflexes
2. Oesophageal trauma or pathology
3. ingestion of corrosive agents
4. Oropharyngeal, pharyngeal, or hypopharyngeal
mass.

COMBITUBE

Advantages

1.

Time needed for insertion is short and less skill is

required
Can be inserted in presence of blood or secretions in the
oropharynx.
Provides comparable ventilation and improved
oxygenation to that of tracheal intubation
It can be used by an anesthesia provider having limited
use of the left arm .
It is well tolerated by the patient during emergence from
anesthesia.
Its use is not associated with high levels of trace gases.
Decreased risk of accidental extubation.
The Combitube provides good but not complete
protection from aspiration

2.
3.
4.
5.
6.
7.
8.

COMBITUBE

Disadvantages

1.

Tracheal suctioning or fiberoptic bronchoscopy is not

possible through the Combitube in the esophageal
position
High airflow resistance
Insertion and removal of the Combitube is associated
with a higher stress response
Trauma to the airway and esophagus
Sore throat and dysphagia.
Unsuitable for use in a patient with latex allergy .
The Combitube is expensive compared to other single
use devices.

2.
3.
4.
5.
6.
7.

RETROGRADE INTUBATION
Retrograde (translaryngeal-guided, guided blind)
intubation is an elective or emergency technique for
securing a difficult airway, either alone or in conjunction
with other techniques.
Retrograde intubation is a useful option in patients who
cannot be intubated by using traditional techniques.
Procedure can be expected to take 5 minutes or more
for completion.

Retrograde intubation set

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

Indications

1.
2.
3.
4.

Difficult intubations
Airway trauma
Oro - Pharyngeal bleed
Cervical spine injury

RETROGRADE INTUBATION

1.
2.
3.
4.
5.

Complications
Sore throat
Trauma
Barotrauma
Pretracheal abscess
The tracheal tube may inadvertently slip out as it is
advanced

CRICOTHYROTOMY

Placing a device through the cricothyroid membrane to

gain control of the airway.
It is part of the ASA and Difficult Airway Society difficult
airway algorithms.
Anatomical considerations

1.
2.
3.

Techniques
Needle Cricothyrotomy
Percutaneous Dilatational Cricothyrotomy
Surgical Cricothyrotomy

NEEDLE CRICOTHYROTOMY

1.
2.
3.
4.
5.
6.
7.

Ventilation Techniques - Jet Ventilation

Devices
A number of jet ventilation devices are commercially
available.
Automatic Ventilator
Manual Jet Ventilation Device
Flowmeter
Oxygen Flush
Anesthesia Breathing System
Manual Resuscitation Bag

Percutaneous Dilatational Cricothyrotomy

CRICOTHYROTOMY

1.
2.

3.
4.

Indications
Upper Airway Obstruction with Inability to Ventilate or
Intubate
Anticipated Difficult Intubation - Cricothyrotomy may be
used as an adjunct to fiberoptic or other intubation
techniques where it is anticipated that intubation may
be difficult to perform.
Procedures Involving the Airway
Cervical Spine Injury

CRICOTHYROTOMY

1.
2.
3.
4.
5.
6.

Contraindications
Intrathoracic Airway Obstruction
Inability to Locate the Cricothyroid Membrane
Complete Airway Obstruction
Paediatric patients
Laryngeal pathology
Decreased compliance

CRICOTHYROTOMY

1.
2.

1.

Advantages
Simple, quick, easy to perform
Prevents tracheal collapse
DisadvantageDoes not provide definitive airway

CRICOTHYROTOMY

1.
2.
3.
4.
5.
6.
7.
8.
9.

Complications
Barotrauma
Trauma
Subcutaneous / mediastinal emphysema
Tracheal stoma granulation
Persistent stoma
Tracheal stenosis
Dysphonia
Vocal cord paresis
Wound infection

American Society of Anesthesiologists Difficult Airway Algorithm.

REFERENCES

Understanding anesthesia equipments Dorsch, 5th edition

Millers text book of anesthesia 7th edition
Clinical anesthesia Morgan
CME Airway- MAMC
Airway management Rashid Khan