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Anaesthesiology
Airway Management
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
13 sections · 199 slides
Overview
- Scope of airway management
- How this topic is built up
- Historical shift in airway practice
- Essential steps in safe airway management
Airway Anatomy
- Design of the human airway
- Major landmarks of the airway
- The laryngeal skeleton
- Laryngeal nerve supply and injury
- The cricothyroid membrane
- Safe puncture site on the cricothyroid membrane
- Ultrasound of the cricothyroid membrane
- The cricoid cartilage and trachea
- Tracheal bifurcation and bronchi
- Anatomic differences between infant and adult larynxes
- Anatomic differences between infant and adult larynxes
How Airway Practice Evolved
- Early understanding of airway obstruction
- Origins of tracheal intubation
- Magill, Rowbotham and blind nasal intubation
- Shift from mask to tracheal intubation
- Limitations of the two 1981 techniques
- Invention of the laryngeal mask airway
- Development of indirect laryngoscopy
- Arrival of videolaryngoscopy
History and Physical Examination
- Airway-relevant history
- Signs and symptoms to seek before induction
- Physical examination features with airway management implications
- Physical examination features with airway management implications (continued)
- Physical examination features with airway management implications (continued)
- Conditions with airway management implications
- Syndromes associated with difficult airway management
- Syndromes associated with difficult airway management
- Syndromes associated with difficult airway management (continued)
- Syndromes associated with difficult airway management (continued)
- Syndromes associated with difficult airway management (continued)
- Why airway assessment tools underperform
- Common airway assessment elements
- Predictive power of bedside screening tests
- Pooled sensitivity and specificity of bedside tests for difficult laryngoscopy
- Combining tests to improve prediction
- Simplified risk score for difficult intubation
- Predictors of difficult videolaryngoscopy
- Explanations for the attending-versus-resident finding
- Conditions that make intubation nonroutine
- Prediction of difficult mask ventilation
- Assessment and predictability of difficult mask ventilation
- Assessment and predictability of difficult mask ventilation (continued)
- Ultrasound in airway evaluation
Preoxygenation
- Principle of preoxygenation
- Time to desaturation with and without preoxygenation
- Time-sparing preoxygenation techniques
- Causes of ineffective preoxygenation
- Preoxygenation in the obese patient
- High-flow nasal oxygen and THRIVE
The Anesthesia Facemask
- Loss of airway control at induction
- Role of the anesthesia facemask
- Holding the anesthesia mask on the face
- Positioning for facemask ventilation
- Jaw thrust and two-handed technique
- The expiratory chin drop
- Inflation pressure as a check on technique
- Nasal airways
- Oral airway insertion technique
- Laryngospasm during mask ventilation
- Timing of neuromuscular blockade at induction
Supraglottic Airways
- Definition and uptake of supraglottic airways
- The family of laryngeal mask airways
- Safety comparison of supraglottic airways and tracheal tubes
- Structure of the LMA Classic
- Size selection for the laryngeal mask airway
- Insertion of the laryngeal mask airway
- Cuff inflation and confirmation of position
- Aspiration risk with the laryngeal mask airway
- Management of gastric contents in the barrel
- Positive-pressure ventilation through an LMA
- The LMA Flexible
- Airway protection from above the mask
- Advantages of the laryngeal mask airway in supraglottic surgery
- Supraglottic airways and bronchospasm
- Removal of a supraglottic airway
- Contraindications to supraglottic airway use
- Complications of supraglottic airway use
- Non-LMA supraglottic devices
- The laryngeal tube
- Laryngeal tube in children and mucosal pressure
- The Cookgas air-Q
- Second-generation supraglottic airways
- Features of the LMA ProSeal
- Features of the LMA ProSeal
- Features of the LMA ProSeal (continued)
- The i-gel
- i-gel compared with the LMA ProSeal
Direct Laryngoscopy and Intubation
- Goal of direct laryngoscopy
- The three-axis model
- Effect of atlanto-occipital extension on airway axes
- The two-axis and tongue-displacement model
- Why Mallampati and thyromental distance interact
- Mallampati and Samsoon-Young classification of the oropharyngeal view
- Lingual tonsil hyperplasia
- The ear-to-sternal-notch position
- Techniques for opening the mouth
- Macintosh and Miller blades
- Performing direct laryngoscopy
- Laryngoscopy in the infant and child
- The Cormack-Lehane laryngeal view scoring system
- Refinements of the Cormack-Lehane grades
- The percentage of glottic opening score
- External laryngeal manipulation
- Passing and positioning the tracheal tube
- Tracheal tube size selection in adults
- Size and length of pediatric tracheal tubes
- Size and length of pediatric tracheal tubes relative to airway anatomy
- The paraglossal approach
- Verification of tracheal intubation
- Failure rates and injury with direct laryngoscopy
Optical Stylets and Videolaryngoscopy
- Principle of image-guided laryngoscopy
- The Bonfils intubation fiberscope
- Bonfils technique and sizes
- The Shikani optical stylet and the Levitan FPS
- Using the Levitan First Pass Success scope
- The Clarus Video System
- Definition and role of videolaryngoscopy
- Video laryngoscopes and a rigid stylet
- Design advantages of the Glidescope
- Glidescope success rates
- Difficulty delivering the tube in videolaryngoscopy
- Cervical spine considerations with videolaryngoscopy
- Glidescope insertion technique
- Soft tissue trauma from the videolaryngoscopy blind spot
- Steps to avoid soft tissue trauma
- The Glidescope Titanium and the C-MAC
- The C-MAC video laryngoscope
- The McGrath videolaryngoscopes
- Channeled videolaryngoscopes
- The Pentax Airway Scope and the Airtraq
- Evidence for the Airtraq
- Evidence for the Pentax Airway Scope
- The KingVision video laryngoscope
- Mouth opening needed for indirect laryngoscopes
- Mouth opening needed for commonly used indirect laryngoscopes
- Mouth opening needed for commonly used indirect laryngoscopes (continued)
Aspiration Risk and Rapid-Sequence Induction
- Aspiration as an adverse anesthetic event
- Obesity and aspiration risk
- Three routes to control gastric contents
- Fasting intervals before anesthesia
- Drugs that reduce gastric acidity and volume
- Sodium citrate and nasogastric drainage
- Pulmonary aspiration: patients at risk, methods to reduce risk, and ASA fasting guidelines
- Pulmonary aspiration: patients at risk, methods to reduce risk, and ASA fasting guidelines (continued)
- Pulmonary aspiration: patients at risk, methods to reduce risk, and ASA fasting guidelines (continued)
- Rapid-sequence induction technique
- Goal and classic form of rapid-sequence induction
- Evidence against classic cricoid pressure
- Modified rapid-sequence induction
Intubation Through a Supraglottic Airway
- Supraglottic airways as intubation conduits
- Design of the LMA Fastrach
- Sizing and success of the LMA Fastrach
- Blind intubation through the LMA Fastrach
- Options when blind intubation fails
- Removing an intubating supraglottic airway
- The Aura-I and air-Q as intubation conduits
- Blind intubation through the air-Q
Extubation of the Trachea
- Extubation as a high-risk period
- Complications of tracheal extubation
- Complications of tracheal extubation (continued)
- Criteria for routine awake extubation
- Criteria for routine awake postsurgical extubation
- Criteria for routine awake postsurgical extubation (continued)
- Deep extubation
- Laryngospasm at extubation
- Residual neuromuscular blockade at extubation
- Sugammadex and the cyclodextrins
- Mechanical airway obstruction after extubation
- Vocal cord dysfunction after extubation
- Drug effects on respiration at emergence
- Identifying patients at risk after extubation
- Clinical situations presenting increased risk for complications at time of extubation
- Clinical situations presenting increased risk for complications at time of extubation (continued)
- The cuff leak test
- Strategies for the difficult extubation
- Airway exchange catheters
- Aligning an airway exchange catheter with the tracheal tube
- Overcoming hang-up during reintubation
- The staged extubation set and scope-guided extubation
Summary
- Core principles of airway management
- Device-related takeaways
- Anatomy and assessment takeaways
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition