Department of Anaesthesia

University of Cape Town

Lecture 2
Airway Management

Effective airway management is essential to maintain life! This is a practical topic, best demonstrated
in theatre, but the principles will be described below.

Airway assessment
In any instance where the airway is managed an assessment of the airway is mandatory. This follows
the familiar format of history; examination and special investigations. This is not merely an exercise
but serves to address and answer the following three management issues:
Is mask ventilation going to be difficult? Cant ventilate
Is laryngeal visualisation going to be difficult? Cant intubate
Is cricothyroidotomy going to be difficult? Cant rescue with surgical airway
Previous anaesthetic history and records may provide invaluable information; as well as grading of the
ease

/

difficulty of intubation. A hoarse voice; stridor or difficulty in phonation may suggest difficulty in
management and likewise any history of congenital, acquired or traumatic disease affecting the
airway.

BONES is a helpful acronym as a reminder of who will be difficult to mask ventilate:
B Beard
O Obesity
N No teeth
E Elderly
S Snoring

Difficulty with intubation - pay attention to the four Ds:
Disproportion
Distortion
Dysmobility
Dentition
Disproportion
Macroglossia (big tongue means limited space in mouth for laryngoscope)
Micrognathia (small chin)
High arched palate
Bony abnormalities
Short thick neck
Distortion
Airway trauma
Epiglottitis
Abnormal larynx (e.g. laryngeal tumours)
Dysmobility
Limited mouth opening (<3 cm)
Fixed cervical spine (e.g. ankylosing spondylitis)
Cervical spine injury
Dentition
A gap between upper teeth (passion gap)
Protruding upper teeth (buck teeth)

Three bedside tests are commonly used to predict the possibility of a difficult intubation. They are:
1. Mallampati score
2. Thyromental distance
3. Extension at the atlanto-occipital joint

In isolation, each test has a poor predictive value, but when used in combination, there is a good
probability that no surprises will be found at laryngoscopy. Occasionally we all get caught out
always have a plan B!

Airway management

2 - 2
Mallampati classification:
This test is performed with the patient in the sitting position, the head held in a neutral position, the
mouth wide open, and the tongue protruding to the maximum. The subsequent classification is
assigned based upon the pharyngeal structures that are visible.

Class I Class II Class III Class IV
Class I =visualisation of the soft palate, fauces, uvula, anterior and posterior pillars
Class II =visualisation of the soft palate, fauces and most of the uvula
Class II =visualisation of the soft palate and only the base of the uvula
Class IV =soft palate is not visible at all

Thyromental distance:
The thyromental distance is the distance of the lower mandible in the midline from the mentum (chin)
to the thyroid notch. This measurement is performed with the patient's neck fully extended. A
thyromental distance of less than 3 fingerbreadths, or less than 6 cm in adults, is predictive of a
difficult intubation.

Extension at the atlanto-occipital joint:
Almost all extension of the head on the neck takes place at the atlanto-occipital joint. Atlanto-occipital
joint extension may be measured when the head is held erect and facing forward. With one finger on
the mentum (under the chin) and one on the occiput; the head is gently extended. The inability to lift
the finger on the mentum above that on the occiput indicates limitation of neck extension. This is
predictive of a greater degree of difficulty with intubation.

Facemask ventilation
Upon induction of anaesthesia, or in states of decreased level of consciousness, there is decreased
muscle tone that may cause upper airway obstruction. If not appropriately managed, this may lead to
hypoxia (low Oxygen saturations) and

/

or inadequate ventilation (raised carbon dioxide).
To provide a patent airway, the following manoeuvres should be performed:
1. Extend the head at the atlanto-occipital joint: A head tilt - chin lift.
2. Then attempt a jaw thrust, by pulling the jaw forward
If this remains ineffective, an oropharyngeal (Guedel airway) or nasopharyngeal airway may be used.

Care should be taken not to cause further airway obstruction by compressing the soft tissues when
holding a facemask. The fingers should be maintained along the bony angle of the jaw only.

In a spontaneously breathing patient, effective mask ventilation can be determined by:
visually inspecting the chest for good expansion during inspiration
absence of accessory muscle use and tracheal tug
inspection of the reservoir bag of the breathing circuit to obtain an indication of the tidal volume

BEWARE: Signs of upper airway obstruction include stridor, tracheal tug and accessory muscle use.
Complete upper airway obstruction with ongoing respiratory effort leads to a see-saw movement of
the abdomen and chest. An inexperienced clinician may miss this (often subtle) sign.
Severe or complete upper airway obstruction may lead to negative pressure pulmonary oedema,
which may necessitate re-intubation and ventilation in intensive care. It usually occurs in otherwise fit
and healthy individuals.
Airway management

2 - 3
Tracheal intubation
Tracheal intubation was first described in humans in 1788 when it was used in the resuscitation of
victims of drowning. It was more than a century later before this procedure became part of
anaesthetic practice.

Advantages:
- A guaranteed airway
- Protection from aspiration of gastric contents
- Ability to provide effective positive pressure ventilation
- Ability to clear secretions from the respiratory tract by suctioning

Indications:
1. Controlled ventilation. Gold standard means of isolating the tracheal & bronchial tree
2. Protection of the airway. A cuffed endotracheal tube provides a measure of protection from the
aspiration of gastric contents
3. Maintenance of a patent airway:
a. Unusual intra-operative position (e.g. prone)
b. Airway is inaccessible (e.g. Head and neck operations)
c. Surgeon and anaesthetist are competing for an area (e.g. ENT surgery)
d. Difficulties with facemask

/

LMA are anticipated (e.g. grossly obese)
4. For postoperative ventilation in intensive care. Protection of airway, and allows for tracheo-
bronchial suctioning.

Equipment:
1) Laryngoscopes
Conventional laryngoscopes have two separate components:
i) Handle: Housing for batteries; may include light source
ii) Blade: Detachable and interchangeable. Of two basic designs a curved (Macintosh) and a
straight (Magill or Miller) blade. Range of sizes.

2) Endotracheal tubes (ETT)
Made from non-toxic, non-irritant plastic. Most have an inflatable cuff near the distal end. Tubes
without cuffs are used predominantly in paediatric practice. The cuff provides an airtight seal between
the outer wall of the tube and the trachea. The cuff is inflated using a syringe via a separate channel.
A pilot balloon is present to indicate whether the cuff is inflated or deflated.
The size of an ETT is stipulated according to its internal diameter. For orotracheal intubation, a size
7,5 8,0 mm tube is commonly used for adult males, and a 7,0 7,5 mm in adult females.
For nasotracheal intubations, this size is usually reduced by 1,0 mm
For children (until puberty), the following formula can be used to estimate the appropriate size:

(age in years / 4) + 4
Always have a size above and below (0,5 mm) to hand.

It is important to ensure that an endotracheal tube is inserted to the correct length. If the tube is
inserted too far, it may result in an endo-bronchial intubation (usually down the right main bronchus
because it is straighter). There is a risk of an inadvertent extubation or damage to the larynx if it isnt
inserted far enough. Some endotracheal tubes will have markings to indicate where the vocal cords
should lie (at the black line); as a rough guide to the correct position. Auscultation should reveal equal
air entry. A chest X-ray will commonly be performed if the patient is likely to remain intubated for an
extended period (e.g. in intensive care) to determine the position of the endotracheal tube.

Rough guide to depth of ETT:
20

2 cm mark at teeth for adult females
22

2 cm mark at teeth for adult males
In children, use the formula:
(age in years / 2) + 12

Airway management

2 - 4
3) Intubating (Magill) forceps
Used to guide the tip of the endotracheal tube through the glottic opening. Beware of damaging the
cuff. Also used for placement of a nasogastric tube into the oesophagus under direct vision;
placement of throat pack; and removal of any foreign body.

4) Introducer (bougie)
Helpful in the more difficult intubation. You can pass the introducer through the vocal cords and then
railroad the ETT over it. It also provides a skeleton for armoured ETTs which are not pre-formed into
a nice curve.

IMALES helpful to remember the equipment needed for intubation
Introducer
Mask, Magills forceps
Airways, Ambubag, Alternate airway (e.g. LMA)
Laryngoscopes
Edotracheal tubes
Suction

Intubation techniques
Always anticipate and predict the possibility of a difficult intubation.

Incorrect head positioning is the most common cause of a difficult intubation. The head is extended at
the atlanto-occipital joint, and the neck (cervical spine) is flexed. Sniffing the morning air (ensure the
patients head is on a pillow). Do not extend the head and neck fully a common mistake made by
beginners.

OROTRACHEAL INTUBATION
Position the patients head on a small pillow, as described above.
Hold the Laryngoscope in the palm of the Left hand and introduce the blade into the right side
of the patients mouth. Advance the blade posteriorly and toward the midline, sweeping the
tongue to the left.
When the epiglottis is in view, advance the tip of the laryngoscope blade into the vallecula,
formed by the base of the tongue and the epiglottis.
Lift the laryngoscope in the direction of the long axis of the handle to bring the larynx into view.
If the epiglottis overhangs the larynx, then advance the blade further into the vallecula. If only
the oesophagus is seen, withdraw the blade a short distance.
When the larynx is in view, introduce the endotracheal tube from the right. A common error is to
obstruct your view with the tube before the glottis is entered.
If only the posterior aspect of the glottis (the arytenoids) is in view, have the assistant apply
gentle backward pressure on the cricoid cartilage so the larynx is brought into full view.
Alternatively, a rigid stylette or forceps may be used to direct the tip of the tube into the larynx.
An introducer (gum-elastic bougie) is commonly used to railroad an ETT in a difficult intubation.
Once the endotracheal tube is in place, apply positive pressure ventilation to the lungs while
your assistant inflates the cuff gradually until an airtight seal is obtained during the inspiratory
phase of positive pressure (minimal occlusion pressure).
Check the position of the tube:
o Auscultate in each axilla and base of the lungs for good equal breath sounds.
o Auscultate the epigastrium There should only be soft transmitted sound No gurgles!
o Check movement of both sides of the chest (especially the apices). Unequal movement
and unequal air entry are signs of an endo-bronchial intubation.
o Humidified air movement can be seen in the clear plastic endotracheal tube as misting.
o There are two absolute methods of knowing that your tube is in the trachea:
1) You see the tube go through the vocal cords.
2) Capnography is a reliable sign of the entotracheal tube being passed into the
correct hole, but will not determine correct positioning.
Disposable CO
2
detectors (discs), that fit onto the ETT are available (expensive)
and may be of value in emergency intubations, e.g. ambulances, emergency
rooms etc.

Airway management

2 - 5
NASOTRACHEAL INTUBATION
This is often used in theatre and in Intensive Care Units (ICU) as an alternative to orotracheal
intubation. In theatre, it allows the surgeon unrestricted access to the oral cavity and is thus
commonly used for ENT, dentistry and maxillo-facial surgery. Its use in ICU for long-term ventilation is
controversial as it is associated with an increased incidence of sinus infection, but is generally better
tolerated by patients and they require less sedation.
The technique is essentially the same as for orotracheal intubation, but the ETT is passed down either
nostril and guided through the cords with the aid of a Magill forceps. The nostril should be prepared
with vasoconstrictor drops (e.g. Ephedrine or Oxymetazoline) to minimise bleeding and the ETT is
softened in hot water prior to insertion. Passage through the nose must not be forced!!

Extubation
This is either awfully simple, or simply awful!
Check that the patient is recovering from the effects of the anaesthesia and is breathing
spontaneously with adequate tidal volumes.
Allow the patient to breathe Oxygen-enriched air at high flow for 1 2 minutes to wash out
Nitrous oxide.
Remove secretions accumulated in the pharynx, mouth and nose by suction.
Check that the patient is not in a semi-conscious state. Extubation at a light level of
anaesthesia can produce laryngospasm. It is probably safest to wait for the patient to be fully
awake and self-extubate if in any doubt.
Turn the patient on his side if he is still unconscious.
Deflate the cuff slowly and remove the endotracheal tube at the end of inspiration with a positive
pressure breath.
Obtaining a good seal with a facemask after extubation will allow the anaesthetist to assess if
the airway remains patent whilst administering supplemental Oxygen (O
2
).
Once satisfied that the airway is being maintained and the patient is breathing satisfactorily,
monitor the saturation with the patient breathing room air.
If supplemental O
2
is required to maintain an adequate saturation, you must determine the
cause and correct it if possible!
Continue supplemental O
2
(F
I
O
2


0,4), if required. N.B. If you need >40 % O
2
to maintain the
sats at >92%, you have a problem! Call for help and provide airway

/

ventilatory support.

Complications
1. Of intubation:
Trauma to nose, lips, teeth, soft tissues of larynx and airway
Bronchial intubation from too deep a tube (common)
Intubation response: Tachycardia, hypertension, dysrhythmias, bronchospasm, increase
in intra-cranial and intra-ocular pressure.
Increased resistance to breathing narrow tube or kinked tube
Obstruction of endotracheal tube: collapse, foreign body, secretions, biting, problems with
cuff, bevel of tube against the tracheal wall
Oesophageal intubation. If in doubt, take it out!
Dislodgement into pharynx or bronchus as a result of inadequate securing of the tube
Failed intubation

2. After extubation:
Laryngospasm. Apply O
2
via tight fitting facemask with continuous positive airway
pressure (CPAP). If necessary use a small dose of Suxamethonium (25 mg) to re-
intubate.
Aspiration of gastric contents if you extubate before protective reflexes have returned (i.e.
a deep

/

asleep extubation). This is prevented by an awake extubation and placing the
patient in the left lateral (recovery) position.
Hoarseness and sore throat
Oedema of trachea and larynx
Ulceration of vocal cords and

/

or trachea, usually only with prolonged intubation
Tracheal stenosis after long-term intubation, may require surgical correction
Airway management

2 - 6
Laryngeal mask airway (Brain airway)
The laryngeal mask airway was developed by Dr Archie Brain, of London, in the 1980s. It is mainly
taking the place of the anaesthetic facemask. It DOES NOT PREVENT ASPIRATION and cannot
always be relied upon to provide positive pressure ventilation.

These are available in sizes 1, 1.5, 2, 2.5, 3, 4, 5 and 6. A size 3 or 4 should be used for adult
females and a 4 or 5 should be used for adult males.

Indications
Properly starved patients without gastro-oesophageal reflux
Failed intubation as a holding measure
Becoming more commonly used for airway management in a cardiac arrest when you cant
intubate

Advantages
Easy to insert with high success rate
Relieves anaesthetists hands to control anaesthetic and make notes
Less stimulating than intubation
Lower incidence of sore throat than following intubation
Can apply positive pressure ventilation (maximum pressure limit of 20 hPa or cmH
2
O to
prevent inflation of stomach)

Disadvantages
Does not protect airway from aspiration
Ventilation not always possible with this device
Laryngospasm may occur with the use of this device

More recently a Proseal laryngeal mask airway has been developed. This includes a gastric
drainage port and produces a better seal for positive pressure ventilation with a reduced risk of gastric
insufflation and aspiration.

Tracheostomy
Indications for tracheostomy include:
1. Prolonged ventilation in ICU
2. Head and neck deformity

/

trauma
3. The impossible airway
4. Tracheal suctioning is easier.

Difficult intubation
The incidence of difficult intubation is 1

:

2 000. A thorough airway assessment should alert you to
the possibility of difficulties with mask ventilation and/or intubation. Be prepared. Have assistance
and the necessary equipment. Make a plan A and a plan B and a plan C! Below is the ASAs Difficult
Airway Algorithm for the stepwise approach to this clinical scenario. Remember, once the patient
stops breathing and youre in a cant ventilate and cant intubate situation; this is a true
emergency and you must work through the steps (in the bottom right quadrant) quickly. If, however,
you can mask ventilate but not intubate, it is not an emergency, because you are able to oxygenate
the patient. You have time to get help and make a plan. You can even wake the patient up and
consider your options. When we anticipate a difficult intubation, we keep the patient breathing
spontaneously. This is crucial to remember. Your options are to intubate awake; or do a gas
induction, keeping the patient breathing while you intubate, then paralyse only once the airway is
secure.

Airway management

2 - 7
ADVANCED AIRWAY MANAGEMENT ALGORITHM
Resuscitation Council of Southern Africa


Airway management

2 - 8
DIFFICULT AIRWAY ALGORITHM
American Society of Anesthesiologists (ASA)