1

Reading:

AIRWAY MANAGEMENT

Sandra Bordi

Sass Elisha

KPSAN/CSUF N581

o Morgan and Mikhail – 309-340

Videos on web-site:

o Introduction to intubation o Managing the airway

Optional

o Whitten, Christine. Anyone Can Intubate, 4th

ed. 2003.

o Barash, Cullen, Stoelting, Cahalan, & Stock, Clinical Anesthesia, 6th

ed.

pp.751-758.

OBJECTIVES:

At the conclusion of this learning session the student will be able to:

1. Apply the Mallampati classification system to a preoperative airway assessment.

2. Discuss the importance of measuring the thyromental distance.

3. Demonstrate how to open a patient’s airway using the head tilt-chin lift maneuver.

4. Demonstrate how to maintain a patent airway using:

a. a mask

b. an oral airway

c. a nasal airway

5. Explain the various components of applying a mask to the face and maintaining an

maintaining an effective seal.

6. List patient characteristics that could alert the nurse anesthetist that a potentially

difficult intubation may exist.

7. Diagram the position of the oral, laryngeal and pharyngeal when a patient’s head is

elevated and the neck is extended.

8. Discuss the components of a pre-intubation checklist.

9. Review the differences between the intraoral vs. extraoral technique of opening the

the mouth before intubation.

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10. Identify the components of glottic opening which include:

a. epiglottis

b. vocal cords

c. cuneiform cartilage

d. corniculate cartilage

e. arytenoid cartilage

11. Discuss the difference in anatomic positioning between using the Macintosh blade

as compared to a Miller blade.

12. Inventory the potential complications during and after intubation.

13. Summarize the technique for performing a nasal intubation.

14. Identify areas on the chest and abdomen that one must listen to confirm proper

placement of an endotracheal tube.

15. List six criteria that are used to confirm proper endotracheal tube placement.

16. Predict the proper depth of endotracheal tube insertion for adult patients.

17. List five criteria that must be met prior to extubation.

18. Discuss proper extubation procedure.

19. Summarize the procedure for proper cricoid pressure.

Revised/Updated August 2009

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AIRWAY MANAGEMENT

Pre operative Airway Assessment:

1. Identifying indicators of difficult bag mask ventilation (BMV) =MOANS

2. Identifying risks for difficult intubation=LEMON

*THE ABILITY TO RECOGNIZE AND TREAT AIRWAY OBSTRUCTION,

THEN VENTILATE WITH A BAG AND MASK IS MORE IMPORTANT THAN

THE ABILITY TO INTUBATE.

♦ Assess For Airway Obstruction

OPENING THE AIRWAY-Head Tilt-Jaw Thrust (Triple Airway Maneuver)

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♦ Check equipment

Ventilating With a Bag and Mask (BMV)

♦ Place in sniffing position and pull head into extension with your left hand.

♦ Place the apex of the triangular mask on the bridge of the nose and press firmly.

♦ Grasp each side of the mask with your hands and spread it as much as you can

♦ As you spread the mask, reach down with your index fingers and pull the loose cheek

tissue forward to bunch on either side of the mouth.

♦ Place your remaining fingers on the jaw and lift upward.

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♦ While maintaining the mask fit and patent airway with your left hand, squeeze the

bag with your right hand

♦ Gastric distention and regurgitation

♦ How do you know if there is air exchange?

1.

2.

3.

4.

5.

5 INDICATORS OF DIFFICULT BAG MASK VENTILATION

1. M=

2. O=

3. A=

4. N=

5. S=

6

What do you do if you cannot ventilate after performing the triple airway maneuver?

1.

2.

3.

4.

Oral Airways

♦ Advantages

♦ Disadvantages

♦ Insertion

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Nasal Airway

♦ Advantages

♦ Disadvantages

♦ Insertion

If you have difficulty placing the nasal airway then:

1.

2.

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History RISKS FOR DIFFICULT INTUBATION

♦ Known previous difficult intubation

♦ Previous upper airway surgery

♦ Excessive snoring/sleep apnea

♦ Radiation

♦ Change in quality of voice

♦ Neck mass

♦ Arthritis

Patient Characteristics That Could Make Airway Management Difficult

♦

♦

♦

♦

♦

♦

♦

♦ Preoperative airway assessment

Mallampati Classification

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How would you assess Mallampati classification?

Thyromental Distance Measurement

♦ Measurement from the lower border of the mandible to the thyroid notch with the

neck fully extended.

♦ Measurements of less than

potentially difficult airway.

♦ Assess mobility of larynx.

cm or three finger breaths can indicate a

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Temporomandibular Joint Mobility

♦ Three finger breaths opening is adequate

♦ Assess for TMJ click

♦ Mandibular glide

♦ Touch chin to chest

♦ Extend head

Atlanto-Occipital Joint Extension

IDENTIFYING RISKS FOR DIFFICULT INTUBATION

1. L=

2. E=

3. M=

4. O=

5. N=

Why is it vital to perform an airway assessment on every patient having anesthesia?

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Preoperative Airway Assessment Length of upper incisors Long Incisors Less room for blade in mouth

Voluntary protrusion of mandibular teeth anterior to

the maxillary teeth

Anterior protrusion of the mandibular teeth relative to

the maxillary teeth

Test of TMJ function

Interincisor distance Greater than 3 cm Ability to open mouth and insert blade

Oropharyngeal classification (Mallampati Classification)

Class I and II

Class III and IV

I and II-Tongue small in relation to oral cavity

III and IV-Tongue large in

relation to oral cavity

Narrowness of palate With greater narrowness Decreased oropharyngeal volume and room for the blade

and ETT

Thyromental distance Greater than 6 cm or greater than three finger breadths

Larynx is relatively posterior to upper airway structures

Length of neck Subjective Decreased ability to align the upper airway axes

Thickness of neck Subjective Decreased ability to align the upper airway axes

Range of motion of head and neck

Neck flexion to chest 35°

Head extended on neck 80°

Ability to achieve a proper sniffing position

GOT TEETH?

♦ Chipped

♦ Broken

♦ Loose

♦ Dentures

♦ Overbite

♦ Braces/Retainers

♦ Tongue rings

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PREOXYGENATION

Cricoid Pressure

♦ Is performed in the following situations:

9 All emergency surgery

9 Obese patients

9 History of gastric acid reflux

9 Diabetics

9 Pregnant patients

9 Optimal external laryngeal manipulation (OELM)

9 Any other patients that are high risk for gastric aspiration.

9 Current controversies regarding cricoid pressure

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♦ Procedure

♦ Contraindications to application of cricoid pressure

� � �

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INTUBATION

THE ABILITY TO RECOGNIZE AND TREAT AIRWAY OBSTRUCTION,

THEN VENTILATE WITH A BAG AND MASK IS MORE IMPORTANT THAN

THE ABILITY TO INTUBATE

Pre-Intubation Checklist

♦ Anesthesia machine check

♦ Anesthetic drugs

♦ Laryngoscope and several different blades

♦ Endotracheal tubes and stylets

♦ Oral airways

♦ Suction

♦ Ambu bag

♦ Preoperative airway assessment

Head Position- Aligning the Axes of the Upper Airway

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♦ The axes must be aligned in to make a straight path from the incisors to the larynx.

♦ The three axes are:

1.

2.

3.

Sniffing Position

Which picture best demonstrates correct sniffing position?

16

Obesity:

17 What is it about these obese patients that may make ventilation and intubation difficult?

Why will desaturation occur rapidly in obese patients?

18

Could she be difficult to ventilate/intubate?

Intraoral Technique

Opening the Mouth for Laryngoscopy

19

Extraoral Technique Opening the Mouth for Laryngoscopy: ExtraoralTechnique

Laryngoscopy and Visualization

ConYentlonat Laryngoeccpy with a Curved Blade

lnser1; the laryngosco- blade Into the

rigt side of the rnou th:;..._., ,

20

Miller vs Macintosh Blade

Intubation sequence:

21

22

Lifting During Laryngoscopy

23

Cormack and Lehane Grading System

24

Placement of an Endotracheal Tube

+ The glottic opening is recognized by its triangular shape and white vocal cords. FRONT OF THE PATIENT

TRACHEAL

RINGS

ARYTENOIDS

(1026)

{ I

Glossoepiglottic folds (median and lateral)

Vocalchords

(true Chords)

Vocal

Tongue-----

Ventricular fold (False chords)

r Aryepiglottic fold

Posterior carltiages

lnterarytenotd notch

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Vocal Corniculate Vocal False vocal

cords --r------, cartilage cords -----.-----,

CORDS APART CORDS ADJACENT

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♦ The endotracheal tube cuff is advanced cm past the vocal cords.

♦ After placement, the laryngoscope blade is removed from the mouth.

♦ The endotracheal tube cuff is inflated, and positive pressure ventilation is instituted.

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Confirmation of Endotracheal Tube Placement

♦ DIRECT VISUALIZATION OF THE ETT BETWEEN THE CORDS

♦ PRESENCE OF END-TIDAL CARBON DIOXIDE

♦ OBSERVATION OF CHEST RISE AND FALL DURING VENTILATION

♦ AUSCULATATION FOR BREATH SOUNDS

♦ CONDENSATION ON THE ETT DURING EXHALATION

♦ RESERVOIR BAG COMPLIANCE AND REFILLING

Intubating the esophagus in most cases is not catastrophic.

The catastrophe occurs if the esophageal intubation is not recognized.

Why isn’t decreased SaO2 used to initially confirm ETT placement?

♦ Depth of insertion

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List signs that would alert you to the fact that the ETT is in the right mainstem bronchus?

List signs that alert you to the fact that the distal end of the ETT is above the vocal cords?

What are your first interventions if an intubated patient is desaturating?

1.

2.

3.

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Listening to Breath Sounds

Can an endotracheal tube migrate? If so where is it most likely to migrate in an adult?

30

- l

ntermedia•c bronch us

-._....:><.::_ u&c

(sup•n.or, lower

lobe)

s&cu

BIK

nor lol

ronthu I,

89 (lalcral basal)

u•o (posterior basal)

SIC>•

B10.JII

BIOboi B9bi p

What is this?

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Are patients prone to developing atelectasis during general anesthesia?

What can increase the potential for atelectasis?

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Taping an Endotracheal Tube

Complications of Endotracheal Intubation and Ventilation

Mechanical: Physiologic:

1. 1. 2. 2.

3. 3.

4. 4.

5.

While Intubated: Upon Extubation:

1. 1. 2. 2.

3. 3.

4. 4.

5. 5.

6.

7.

8.

9.

Nasal Intubation

♦ Why perform a nasal intubation?

9 9 9

♦ Contraindications:

9 9 9

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♦ Procedure

Preoperative preparation

♦ Complications

9 9

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EXTUBATION CRITERIA

9 Recovery of airway reflexes

9 Responds to command

9 Absence of hypoxia/hypercarbia

9 Absence of cardiac instability

9 Inspiratory capacity of 10-15 cc/kg

9 Absence of gastric distention

9 Spontaneous respiration

9 Absence of residual neuromuscular blockade

9 Verification of intact neuromuscular functioning

9 ♦ Prior to extubation, all patient’s are to be preoxygenated with 100% oxygen

♦ Patient’s must be orally suctioned prior to extubation

♦ Suction endotracheal tube as needed

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Burnett, J., & Patil, V. Airway Management. In McIntosh, L. Essentials of Nurse

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Hester, C. A comparison of preoperative airway assessment techniques: The modified

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