AIRWAY MANAGEMENT

Mr. Lokesh K A
MSc RT
 Types of Artificial
Airways
Nasopharyngeal Airway (NPA) Oropharyngeal Airway (OPA)

Soft tube inserted through nostril for semi-conscious Curved device preventing tongue obstruction
patients with intact gag reflex. in unconscious patients without gag reflex.

Endotracheal Tube (ETT) Tracheostomy Tube

Tube inserted into trachea for ventilation Tube placed through surgical stoma in
in unconscious or respiratory failure patients. trachea for long-term ventilation.
 NASOPHARYNGEAL
AIRWAYS
A nasopharyngeal airway resembles a shortened tracheal tube
with a flange at the outer end to prevent it from completely
passing into the nares.

The size of a nasopharyngeal airway is designated by the inside

diameter in mm.
Nasal intubation

– Commonly used for surgical procedures

involving the oral cavity or oropharynx
– Mandible fracture
– Limitation in movement in
temporomandibular joints
– Neck injury
– Cervical spine disease
– Patients who do not tolerate direct
laryngoscopy
SPECIFIC
AIRWAYS – It is plastic with a large flange
– The distal end has no bevel.
– Airway is supplied by an introducer, which has a
Linder balloon on its tip.
nasopharyngeal – Before insertion, the introducer is inserted into the
airway until the tip of the balloon just passes the
airway end.
– The balloon tip is inflated to approximately to the
outside diameter of the tube.
– After it is in place the balloon is then deflated and
the introducer removed.

– Consists of two nasal airways joined

Binasal Airway
together by an adapter for attachment
to the breathing system.
 COMPLICATIONS
 Airway obstruction
o The tip of an airway can press the epiglottis or tongue against the posterior pharyngeal
wall and cover the laryngeal aperture.
 Trauma
o Injury to the Nose and posterior pharynx
o Pharyngeal perforation
o Retropharyngeal abscess formation
 Tissue edema
 Ulceration of the nose or the tongue and necrosis
 CNS trauma e.g. basilar skull fracture
 Laryngospasm and coughing
 Retention aspiration or swallowing
 Oropharyngeal Airway (OPA)

1 Measurement Measure from corner of mouth to jaw angle for proper sizing.

2 Insertion Insert with concave side up, rotating 180 degrees as it enters the mouth

3 Monitoring
Check for consciousness and potential obstruction regularly.
Remove if gag reflex returns.
 SPECIFIC AIRWAYS

Guedel airway
–it has a large flange, tubular air channel, and a
reinferred bite portion.

Berman airway
- has a center support and open sides. The center
support may have openings. There is a flange at the
buccal end. The side opening can be opened wider to
engage or disengage a tracheal tube.

Patil-Syracuse Endoscopic Airway

-designed to aid fiberoptic intubation. It has lateral channels and a
central groove on the lingual surface to allow a fiberscope with a
tracheal tube to pass.
WILLIAM’S AIRWAY INTUBATOR

BROOKS AIRWAY
SUPRAGLOTTIC AIRWAY DEVICES
(SGADS)

CLASSIFICATION

INDICATIONS FOR SGAD’S

CONTRAINDICATIONS FOR SGAD’S

MAIN DRAWBACKS OF SGAD’S

 CLASSIFICATION
BASED ON GENERATION (COOK’S) BASED ON SEALING MECHANISM (MILLER’S)
 1st generation devices – simple airway tubes  Cuffed Perilaryngeal Sealer:-
— classic LMA — Non-directional Non-esophageal Sealers: c-LMA,
— flexible LMA Flexible LMA,LMA unique.
— cobra PLA — Directional Non-esophageal sealing: Fastrach LMA,
— Unique LMA ALMA.
 2nd generation – with addition of drainage tubes — Directional Esophageal sealing : Proseal LMA, LMA
— proSeal LMA Supreme.
— supreme LMA  Cuffed Peripharyngeal Sealer:-
— SLIPA — Without esophageal sealing: COPA, PAX.
— I-gel — With esophageal sealing: Combitube, LT, LTS.
 3rd generation – cuffless, 2 drain tubes, small
bowl
 Cuffless Preshaped Sealer: -
— BASKA mask
— With esophageal sealing: Baska Mask, I-
— Elisha
Gel.
— 3gLM
— Without esophageal sealing: SLIPA , AirQ-SP.
 BASED ON THE NUMBER OF LUMEN
Single Lumen Devices:-

LMA-classic, LMA-unique, LMA-flexible, ILMA, C-trach, Soft seal,

Laryngeal Airway Device (LAD), Ambu Laryngeal Mask,
Pharyngeal airway express (PAX), Cobra Perilaryngeal
Airway (CPLA), Laryngeal Tube (LT), Cuffed oropharyngeal airway,
Stream Lined Liner of the Pharyngeal Airway (SLIPA), Glottic
Aperture Seal Device.
Double Lumen Devices:-

Proseal LMA, Combitube, Laryngeal Tube Suction (LTS),

Airway Management Device (AMD)

Tripple Lumen Devices:-

Elisha Airway Device (EAD).

 INDICATIONS FOR
SGAD’S
 Quicker and Easier Placement by inexperienced personnel
 Increased speed of placement
 Reduction in usage of neuromuscular blocking drugs
 Reduced anesthetics requirement for airway tolerance
 Improved hemodynamic stability during emergence
 Minimal IOP and ICP changes during placement
 Preservation of laryngeal competence and mucociliary function
 Lower incidence of cough during emergence
 Improved oxygen saturation during emergence
 Lower incidence of sore throat post procedure
 CONTRAINDICATIONS FOR SGAD’S
 Limited mouth opening (< 2 fingers)

 Local pathology in pharynx , larynx or upper airway.

 Trismus, facial or upper airway trauma

 Increase risk of aspiration- Morbid obese, > 14 week pregnant, prior

opioids medication, delayed gastric emptying, acute abdominal or
thoracic injury, history of GERD, and hiatus hernia.

 Reduced lung compliance/increase work of breathing

 LMA CLASSIC/ STANDARD LMA

 The LMA classic consists of a curved tube connected to an elliptical

spoon shaped mask at a 30degree angle.
 There are two vertical bars where the tube enters the mask to
prevent the tube from being obstructed by the epiglottis.
 An inflatable cuff surrounds the inner rim of the mask
 An inflation tube and self-sealing pilot balloon are attached to the
proximal wider end of the mask.
 At the machine end of the tube is a 15mm connector.
 LMA CLASSIC/ STANDARD LMA

INSERTION

Standard technique
 Use a midline of slightly diagonal approach with the cuff
fully deflated
 Patient’s head in SNIFFING Position
 The tube portion is grasped as if it were a pen with the
index finger pressing on the point where the tube joins
the mask.
 With the aperture facing forward (and the black line
facing the patient’s upper lip), the tip of cuff is placed
against the inner surface of the upper incisors.
 The mask portion is pressed against the hard palate
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ures/how-to-insert-a-laryngeal-mask-airway
Other Techniques
 180 Degree Technique : To insert the LMA with the laryngeal aperture pointing
cephalad and rotate it 180 degrees as it enters the hypopharynx. This method may
be as satisfactory as standard technique in pediatric patient.

 Partial inflation technique :To partially or fully inflate the cuff before insertion.
This technique may offer some advantages for an inexperienced users, but the
device may frequently be malposition.

 Thumb insertion technique : LMA is held with the thumb in the position
occupied by the index finger in standard technique. It is more suitable for patients
where access to the head from behind is difficult.
 THE CLASSICAL LARYNGEAL MASK SIZES

LMA size Patient size

1 Neonates/Infants up to 5 KG
1.5 Infants between 5 to 10 KG
2 10-20
2.5 20-30
3 30-50
4 50-70
5 70-100
6 >100

A method to choose the correct size laryngeal mask for children is to match the widest part of the
mask to the width of the 2nd to 4th fingers
 TRACHEAL INTUBATION WITH THE LMA CLASSIC

LMA can serve as a conduit through which a tracheal

tube, stylet or fiberscope is passed
Techniques for tracheal intubation:
LMA size Largest size of Largest size
 Blind Tracheal tube of Fiberscope
1 3.5 2.7
 After LMA is inserted, the tracheal tube is well lubricated
1.5 4 3
and inserted into the tube 2 4.5 3.5
 The tracheal tube should be rotated 15 Degrees to 90 2.5 5 4
3 6 cuffed 5
Degrees counter clockwise as it is advanced to prevent
4 6 cuffed 5
the bend from catching on the bars at junction of tube
5 7 cuffed 5
and mask 6 7 cuffed 5
 Other techniques:
 Fiberscope guided
 Retrograde wire technique
 Lighted stylet guided
 LMA UNIQUE

 Single use LMA Unique

 Made of polyvinylchloride and costs lesser
 Tube is stiffer and cuff less compliant
 May be a better choice for out-of-hospital or ward use,
where it would be difficult to clean and sterile.
 LMA FLEXIBLE

 It has a flexible, wire reinforced tube

 Can be bent to any angle without kinking
 Allows it to be positioned away from the surgical field without
occluding the lumen or losing the seal against larynx.
 Insertion is more difficult
Use
 Designed for use with surgery on head, neck and upper torso
• Has 4 main Parts
o Posterior inflatable cuff
o Inflation line with pilot balloon
o Airway tube
o Drain(gastric access tube)
• All components are made of silicon and are latex free
• Available in 6 sizes,
• size 4 for most adult women and size 5 for most adult men
ADVANTAGES OF PROSEAL

It allows liquids and gas to escape from the

stomach

Reduces the risk of gastric insufflation and

pulmonary aspiration.

Allows devices to pass into the esophagus and

provides information about the LMA Proseal
position

A gastric tube, Doppler probe, thermometer, can

be passed through the drainage port
 LMA FASTRACH
It is also known as intubating LMA.
 It has a short, curved stainless steel shaft, Sufficient diameter
 Short enough to allow a standard tracheal tube cuff to pass beyond vocal
cords
 The metal handle is securely bonded to the shaft near the connector end to
facilitate one handed insertion, position adjustment and maintain the device
in a steady position during tracheal tube insertion and removal.
 A “V” shaped guiding ramp is built into the floor of the mask aperture to direct
the tracheal tube towards the glottis

Use
 Designed to facilitate tracheal intubation
 Can also be used as a primary airway device.
 Useful for the anticipated or unexpected difficult airway.
 LMA - C TRACH

 It has two built in Fiberoptic channels

 One to convey light
 Other to convey image to the viewer
 These emerge at the distal end of the airway tube
under the epiglottic elevating bar, which lifts the
epiglottis as the tracheal tube passes through the
LMA –C Trach into the larynx.
 The monitor is attached to the LMA-C Trach via a
magnetic latch connector
 Available is size 3,4 and 5 and is reusable
LMA LMA
Unique Proseal

LMA
Fastrach
LMA SUPREME
 I-GEL
 Innovative second generation supra glottic
airway.
 Made from a thermoplastic elastomer
 I-gel has been designed to create a non-
inflatable, anatomical seal of the pharyngeal,
laryngeal and perilaryngeal structures while
avoiding compression trauma.

What makes I-gel unique?

I-gel has a soft, gel-like, non-inflatable cuff,
designed to provide an anatomical impression fit
over the laryngeal inlet.

The shape, softness and contours accurately

mirror the perilaryngeal anatomy an
innovative concept meaning NO cuff inflation
is required.
 BASKA MASK

An oval, anatomically curved airway tube

A Tab to help negotiate the palato-pharyngeal

curve

Two large tubes entering the sump area for high

suction clearance of the sump

A large sump reservoir to collect any fluid entering

the pharynx

A bite block over the full length of airway tube

A non-inflatable flexible membranous silicon mask

 LARYNGEAL TUBE AIRWAY

 Airway tube is wide, curved, color coded

 Small(esophageal, distal )cuff

 Large (oropharyngeal , pharyngeal) in the

middle

 1 inflation tube to inflate both cuffs

 2 anterior facing ventilation holes

 Side holes lateral to top of distal opening

PERI LARYNGEAL AIRWAY
( COBRAPLA)
 Single use , plastic device
 High volume, low pressure oval cuff that is shaped
to fit hypopharynx
 Sniffing position
 Insert straight back into the mouth

STREAMLINED PHARYNX AIRWAY

LINER(SLIPA)
 Plastic uncuffed disposable
 Anatomically fits pharynx
 Toe – rests in esophageal entrance
 Bridge –fits in pyriform fossa
 Heel –anchors to soft palate & connected to airway
tube

Soft seal laryngeal mask
- clear , disposable , made up of PVC
- oval cuff , airway tube , inflation tube, no
aperture bars
- partially inflate cuff and insert.

Ambu laryngeal mask

- tube is larger, more rigid &

pre-curved
SITUATIONS WHERE LMA IS USEFUL
 Difficult face mask technique
 Difficult or failed intubation
 Ophthalmic surgeries(as IOP is lower after inserting an LMA than a tracheal
tube)
 Tracheal procedures
 Endoscopy
 Tracheal tube exchange
 Trans-esophageal ECHO
 Head and neck procedures
 Pediatric patients(in whom unusual anatomy makes tracheal intubation
difficult)
 Supplementing regional block
 Resuscitation
 Neurosurgeries like v-p shunt where high bp after insertion must be
avoided
Advantages of using LMA Complications of using LMA

 Ease of insertion  Aspiration of gastric contents

 Smooth awakening  Gastric distension
 Avoiding complications of  Foreign body aspiration
intubation  Airway obstruction due to mal position ,
 Protection from barotrauma epiglottis back folding, arytenoid
 Cost effectiveness dislocation, tube kinking etc.
 Trauma(to epiglottis, posterior pharyngeal
wall, uvula, soft palate, tongue, tonsils
etc.).
 Sore throat
 Nerve injury- Hypoglossal, RLN and Lingual
Esophageal- Tracheal tube (Combi tube)

2 sizes:
• The smaller size (37F) is used in patients 4 to 5.5
feet tall
• The larger size (41F) is used in patients more than
5 feet tall.

Insertion technique:
Cuff inflation
Pharyngeal cuff 85ml – 100ml
Tracheal cuff 12ml – 15ml
Confirm tube location and select the lumen for
ventilation
• Esophageal placement
• Tracheal placement
• Unknown placement
/www.merckmanuals.com/professional/multimedia/video/how-to-insert-an-esophageal-tracheal-combitube
 Indications Contraindication
s
• Pre-Hospital emergencies
 Trauma cases
 Cardiac arrest • Responsive patients with cough or gag
 Limited resources reflex
• Age 16 years or younger
• Difficult airway scenarios
 Failed intubation attempts • Height 4 feet or shorter
 Inexperience with intubation • Known or suspected esophageal disease
• Ingestion of a caustic substance
• Sedated/ unconscious patients
 Anesthesia emergencies
 Unresponsive patients

• Restricted environments
 Pre-hospital environment
 Rescue and mass casualty
 ENDOTRACHEAL TUBES

General Principles
 It places a mechanical burden on the
spontaneously breathing patient
 It adds resistance and is usually a more important
factor in determining the work of breathing than
the breathing system.
Factors which help to determine the resistance
— Tube size
— Tube length
— Internal diameter
— Configuration
— Tube Design
— Angle of bevel
— Murphy eye
 CUFF

Low volume, high pressure cuff

 It has a small diameter at rest and a low residual volume i.e. the
amount that can be withdrawn from the cuff after it has been allowed
to assume its shape
 It requires a high inflation intracuff pressure to achieve a seal

Advantages
 Better protection against aspiration
 Better visibility during intubation
 Lower incidence of sore throat

Disadvantages
 Pressure on tracheal wall difficult to determine
 Ischemic damage to the tracheal wall mucosa, following prolonged use
High Volume, low pressure cuff

 Has large residual volume and diameter

 No stretching of tracheal wall

 As the cuff inflates, the area of contact becomes larger and the cuff adapts itself to the tracheal surface

 With controlled ventilation, when airway pressure exceeds intra cuff pressure, positive pressure will be applied

to the lower face of the cuff  The air in the cuff will be compressed until intra cuff pressure equals airway

pressure

Advantages

 The intra cuff pressure closely approximate the pressure on the tracheal walls, thus it is possible to measure and

regulate the pressure exerted on tracheal mucosa

Disadvantages
 More difficult to insert
 May obscure the view of the tube tip and larynx
 It may not effectively prevent fluid from leaking into the lower airway even at cuff pressures as high as 60cm
H2O
 SPIRAL EMBEDDED
COLE TUBE RING-ADAIR-ELWIN
TUBES
( RAE) TUBE
 
Multiple studies found that the ideal tube in the average adult is a 7.5 mm
Size interior diameter tube for females and an 8.5 mm interior diameter tube for
males.
 Age is recognized as the most reliable indicator of the appropriate tracheal tube
size for Children
Different recommendation to choose
tube size in children
Recommended
PENLIGTON’S FORMULA Tube sizes
COLE'S FORMULA for
(tube size = 0.25 x age + 4)
Children
Is for the estimation of uncuffed endotracheal tube size
For children < 6 Years
Age (Years) Normal size
 Internal Diameter = Age in years/4 + 4 or 3.5
Age in Years/3 + 3.75
14 7.5 - 8
12-13
Internal Diameter = -3mm
7 7.5 for those 3 months of age and younger
10-11 6.5 – 7 = 3.5mm for those from 3 to 9 months
For children > 6years 8-10
of age 6 - 6.5
6-7 5.5 - 6
Age in years/4 + 4.5 = (age in years +16)/4 over 9 months of
4-5 5 – 5.5
age
1.5-4 4.5 - 5
 Internal Diameter = 2.44
9-18 Months + (age* 0.1) + (height in cm * 0.02) + (weight
4 – 4.5
Full termin kg * 0.016)
9 months 3.5 – 4
premature 2.5 - 3
Depth of Insertion
 In adults the tube should be inserted until the cuff is 2.25 to 2.5 cm below the
vocal cords
 In children under 6 months, if no cuff is present , the tube tip should be inserted
not more than 1 cm past the cords
 And not more than 2 cm past the cords in patients up to 1year
 And not more than 3 to 4 cm past the cords in larger patients
 In average sized adult patients securing the tube at the anterior incisors at 23 cm
in males and 21cm in females has been shown to be a reasonable starting point
for tube placement
For nasal intubation
 2-3cm should be added to these lengths for positioning at the nares
 COLE’S FORMULA for depth of insertion in children:
 Tracheostomy tube

Indications
Obstructed upper airway
Prolonged artificial ventilation
The patient is undergoing surgery to or around the
upper airway
Indications for laryngectomy
The patient is unable to maintain an airway
independently