AIRWAY MANAGEMENT

Dr Kamani Wanigasuriya
Activity Leader/Skills lab
Reviewed by:
Dr Mala Nanayakkara
Consultant anaethetist, CSTH

Contents:

1. Objectives
2. Anatomy of airways
3. Airway obstruction
4. Opening the airway
5. Ventilation
6. Adjuncts to basic airway techniques
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 7. Endotracheal intubation
AIRWAY MANAGEMENT

Introduction
Airway management is the priority in critical care. It is a process of ensuring the
patency of the airway in an unconscious patient or semiconscious patient.
Common situations where airway management is carried out are during
cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care
medicine and trauma management. Majority of deaths that occur after trauma is
due to airway obstruction which is preventable.

1. Objectives

At end of the teaching session the students should be able to,

 Recall the structure of the upper and lower airways
 List the causes of air way obstruction
 Recognise air way obstruction
 Demonstrate the technique of airway management
 Use simple adjuncts to maintain airway patency
 Use simple devices for ventilating victims

2. Anatomy of the Airway

Successful airway management requires a detailed understanding of upper and

lower airway structure and function.

Upper airway – All structures located above the glottis; nasal cavity, oral
cavity, nasopharynx, oropharynx and larynx.

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 Lower airways- Below the glottis to the lungs: trachea, bronchial tree, carina,
bronchioles and alveoli.

3. Airway obstruction:

Obstruction may occur at any site within the airway, from the upper airways to
the bronchi.

Common causes are,

Upper Airway
 tongue (in an unconscious patient)
 soft tissue swelling
 blood, vomit
 foreign body
 direct injury

Lower Airway
 secretions, oedema, blood

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 bronchospasm
 aspiration of gastric contents
 foreign body
3.1Recognition of Airway obstruction

LOOK, LISTEN & FEEL

 LOOK for chest/abdominal movements
 LISTEN at mouth and nose for breath sounds and abnormal noises
 FEEL at mouth and nose for expired air

3.2 Abnormal sounds in airway obstruction

Partial obstruction is noisy and complete obstruction is silent!

Partial obstruction-noisy
 Stridor – obstruction at the larynx or above

 Snoring - due to obstruction of upper airway by the tongue

 Gurgling - due to obstruction of upper airway by liquids (blood, vomit)
 Wheezing - due to narrowing of the lower airways

Complete obstruction
• Paradoxical chest and abdominal movements (see- saw breathing)
• Other accessory muscles used.
• Silent chest (normal breathing is quiet)

4. Opening the airway

Three manoeuvres:
• Head tilt
• Chin lift
• Jaw thrust

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 1. Head tilt and Chin lift

2. Jaw trust
If clear airway cannot be achieved, look for other causes.
 Foreign body
 Broken or dislodged dentures
 Leave well fitting dentures-help maintain contours of the mouth.

5. Ventillation

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  Mouth to mouth
 Mouth to nose
 Bag-valve- mask

Face Mask:

Delivery of ventilation by means of a face mask (or bag-valve-mask device) is an essential skill to
develop. An air-tight properly fitted mask and a patent airway are necessary for successful
ventilation.

1. Select the correct size; it should cover the mouth and nose and should fit properly against
the cheeks.

2.Place the patient in the sniffing position and place the mask over the patient's mouth and
nose with the right hand.

3. With the left hand, place the small and ring fingers under the patient's mandible, and lift up
to open the airway. Make an "OK" sign with your thumb and and index finger, and press it to
the patient's face .

4. Compress the bag with the right hand. The chest should rise
with each breath. If not, reposition the mask , and try again.

Do not pull the mask into the face. Pull the face into the
mask!

5. If an assistant is available to squeeze the ventilation bag ,

use both hands to secure an air-tight seal.

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 6. Adjuncts to basic air way techniques

It is essential to maintain airway open. Position of head and neck must be maintained to
keep the airway aligned.
To overcome tongue displacement following simple devices are available.
1. Oropharyngeal airways- only in unconscious patients
2. nasopharyngeal airways- not deeply unconscious ,better tolerated
3. Laryngeal mask airway
1. Oropharyngeal airway (OPA) – OPA is a curved plastic tube that creates an air passage
between the mouth and the posterior pharyngeal wall. Useful to prevent the tongue falls back
against the posterior pharynx in anesthetized or unconscious patients.

Insert the oral airway upside down up to the soft palate. Then rotate it 180 degrees to slip it
over the tongue.

OPA is poorly tolerated in conscious patients and may cause gagging, vomiting and aspiration.

Oro-pharyngeal airways

Insertion of oropharyngeal airway

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 1. Select the correct size

2. Inserting the oropharyngeal air way (A&B)

2. Nasopharyngeal airway (NPA)

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Nasopharyngeal airway is inserted through one nostril to create an air passage between the
nose and the nasopharynx.

 NPA is better tolerated in conscious patients

than OPA as it is less likely to induce gag
reflex.
 NPA are contraindicated in patients who are
on anticoagulants, patients with nasal
infections and deformities and also in
children as it can induce nasal bleeding.

 Need to check the patency of the nostril

before insertion. Select the patent nostril.

3. Laryngeal mask airway (LMA)

Laryngeal Mask Airway consists of an inflatable silicone mask and rubber connecting tube. It is
inserted blindly into the pharynx. Once inserted, it forms a low-pressure seal around the
laryngeal inlet and permits gentle positive pressure ventilation

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Indications:
• Situations where using a mask is difficult

• Patients whom endotracheal intubation is not successful.

Laryngeal mask airway is in position.

Contraindications for LMA:

 Patients with multiple or massive injury
 Massive thoracic injury

 Massive maxillofacial trauma

 Patients at risk of aspiration

 Morbidly obese patients

 Obstructive or abnormal lesions of the oropharynx

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 7. Endotracheal Intubation

7.1 Indications
• When it is difficult to maintain the airway with triple maneuver and other devices
• Unable to protect own airway
• Risk of aspiration

7.2 Equipment required

1. Self-refilling bag-valve-mask (eg, Ambu bag) , connector, tubing, and oxygen source..
2. Laryngoscope with curved (Macintosh type) and straight (Miller type) blades of a size
appropriate for the patient.
3. Endotracheal tubes of several different sizes.
4. Oral airways.
5.. Introducer (stylets or Magill forceps).
6.. Suction apparatus
7. Syringe, 10-mL, to inflate the cuff.
8. Water-soluble sterile lubricant.
9. Gloves.
Drugs – need sedation and paralysis except in cardiac arrest

7.3 Patient Positioning (Adults)

Goal is to align 3 planes of view, so vocal cords are most visible.

– T - trachea
– P - Pharynx
– O – Oropharynx
1. Elevate the patient's head and flex the neck about 10 cm with pads under the occiput.

2. Extend the head at the atlanto-occipital joint (sniffing position). This will align the oral,
pharyngeal, and laryngeal axis, so that the passage from the lips to the glottic opening is
almost a straight line. This will allow better visualization of the glottis and vocal cords and
allows easier passage of the endotracheal tube.

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 7.4 Procedure

1. Check the laryngoscope and blade for proper fit, and make sure that the light is working.

2. Open the patient's mouth with the right hand, and remove any dentures.

3. Hold the laryngoscope in the left hand. Open the patient's lips, and insert the blade
between the teeth.

4. Pass the blade to the right of the tongue, and advance the blade into the hypopharynx,
pushing the tongue to the left. Lift the laryngoscope upward and forward to expose the
vocal cords.

5. While visualizing the glottis and vocal cords , gently pass the tube next the laryngoscope
blade through the vocal cords into trachea, far enough so that the balloon is just beyond
the cords.

6. Withdraw the stylet. Inflate the balloon with 5-8 mL of air.

7. Check proper positioning of the tube by ,

Symmetric rise and fall of chest
1.
Presence of breath sounds Auscultate over the apex and mid axillary line
2.
Absence of epigastric sounds by auscultation
3.
Chest Xray
4.
8. Connect the patient to the ambu bag/ventilator and ventilate

7.5 Complications of ET intubation

1. Soft tissue trauma/ bleeding

2. Dental injury
3. Laryngospasm
4. Vocal cord injury
5. Hypoxia during the procedure
6. Oesophageal intubation
7. Endobronchial intubation

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