Airway Devices Management

Airway Devices Management Basics

1. AIRWAY DEVICES AND
THEIR SPECIFICATIONS
Dr . S.K. Varma
KG Hospital, Coimbatore

2. Classification
Extra glottic
Intra glottic

3. Simple Airway Devices
Face Mask
OropharyngealAirways
Nasopharyngeal Airways

4. Face Mask
Positive pressure
Ventilation
Airway Patent
Tight Fitting
Clear and transparent
Various sizes and flavors
Short term airway
management with ambu
bag or anaesthetic circuit

5. Signs of successful seal and
ventilation
•the rising of the chest with delivery of positive
pressure
•breath sounds on auscultation
•a firm/taught/full bag
•return carbon dioxide on exhalation capnography
•Foggy Mask

6. Oropharyngeal Airway
Guedel’s Airway
Various sizes and
colour coded
Pre hospital
emergency care or
short term airway
management
Unconscious patient
Stimulate gag reflex

7. Risks of use
Patient may vomit if they have intact gag
reflex
Too large can close glottis and obstruct the
airway
Insertion can become traumatic and cause
bleeding

8. Nasopharyngeal airway
Well tolerated
Various sizes
Length is measured
from nostril to meatus
of the ear
Contraindicated in
basal skull fracture and
anti coaguated
patients
Well lubricated

9. Supraglottic Airway
Placed above the vocal cord level
Those devices which allow hands-free
maintenance of an open airway
Allows spontaneous or assisted
ventilation

10. General Characteristics
Ability to be placed without direct visualization
Better cardio vascular stability both during insertion
and removal
Minimal IOP and ICP changes
Provide little protection against aspiration
Contraindicated in full stomach patients

11. 1908 to date
1908-Hewitt Airway
1913-Connell
1915-Lumbard
1933 –Guedel
1957-Fink vallecular
1957 –Safar Airway
1977 –Berman intubating
1982 –PatilSyracuse
1983 –Laryngeal Mask –Archie Brain
1985 –Combitube
1997 -Intubating LMA
2000 –ProsealLMA
2003 -Cobra Pharyngeal lumen Airway

12. Dr. Archie Brain

13. Laryngeal Mask Airway
Tube with an inflatable cuff
which is inserted into the
Pharynx
Used in elective anaesthesia
Emergency medicine for
airway management by
paramedics
Spontaneous and controlled
Both disposable and reusable
Various sizes -8

14. Laryngeal Mask Airway
Incidence of aspiration is 2 in 10000 (0.02%)
One death attributed directly to LMA out of 2
million users
It is included by the American Task Force in
the difficult airway algorithm in 1995
C. Keller et al –Aspiration and LMA –a review of literature
BJA 93(4) 579-82: 2004
Brimacombe JR et al-The Larynfeal Mask Airway-in the
difficult airway. Anaesthesiology clin of North America
June 13(2) ; 411-37 : 1995

15. Proseal & LMA Supreme
Has two separate tubes
Sizes 1-5 are available
Improved airway
protection
Holds a better cuff seal
pressure
Requires greater depth of
anaesthesia

16. Flexible LMA
Flexo metallic tube
Preformed angle
Better placement
Less incidence of dislodgement
once placed
More useful in head and neck
surgery

17. Tracheo Esophageal Combitube
Double lumen and
double balloon device
Allows ventilation
independent of its
position
Excellent rescue device
both in and out of
hospital emergency
situations

18. King LTD Design

19. King LTS-D Airway Design

20. INSERTION STEPS
Use lateral approach
Introduce the tip into corner
of mouth
Advance behind the base of
tongue
Without exercising excessive
force, advance until the base
of the connector is aligned
with teeth.
Inflate the cuff

21. FINAL POSITION

22. Cobra plus tube
Distal end has softened
openings
Used for both spontaneous
and controlled ventilation
Serves as a rescue airway

24. Single use, noninflatable
Integral gastric channel
Various sizes
Moulding feature

25. Streamlined liner of Pharyngeal airway -
SILPA
Cuffless
Lines the pharynx
Large internal volume –
Allows collection of
secretion, minimize
aspiration
Minimal expertise for
insertion

26. Advantages
Speed & ease of
insertion.
Improved
haemodynamic stability
on induction &
emergence.
Minimal increase in IOT.
Decrease anaesthetic
requirements for airway
tolerance.
Decreased coughing &
sore throat.

27. Intraglottic devices-History
1864-First endotracheal anaesthesia using
tracheotomy cannula by German surgeon
1880-Sir William Macewen –Glasgow
surgeon was the first to introduce
orotracheal intubation
1921-Sir Ivan Magill endotracheal rubber
tubes
1928-Cuffed endotracheal anaesthesia

28. Indications for endotracheal
intubation
Airway Protection
Pulmonary toileting
Applications of positive pressure
ventilation
Maintenance of adequate oxygenation

29. Endotracheal tubes
Non Toxic,Non allergic
PVC tubes –
inexpensive most
compatible with
tissues
Red rubber tubes not
used nowadays

30. Endotracheal tube

31. Endotracheal tube

32. ETT -Cuff
High Volume Low
pressure cuffs-PVC
tubes-less prone for
pressure necrosis
Low Volume high
pressure cuffs –red
rubber tubes-more
prone

33. Endotracheal tube

34. Endotracheal tube

35. Endotracheal tube

36. RAE Tubes
Ring , Adair Elvin Tube
Orosurgical, ENT,
Maxillofacial surgeries
Preformed Bend
Problem with
suctioning

37. Paediatric tubes
Uncuffed tubes
Varoius sizes available
Formulas are available
to guide tube selection
Pediatric airway is
more susceptible
Black mark indicates
depth of insertion

38. Armoured or Reinforced ETT

39. Laser Resistant tubes

40. Laser Resistant Tubes

41. Micro laryngeal trachealtubes
Standard tube length
and cuff size with
smaller ID and OD
(4,5,6mm)
Smaller diameter is
helpful if there is tumor
in the airway.
Used in microlaryngeal
surgery

42. Hi Lo EvacETT with evacuation
Lumen
Designed to reduce
Ventilator Associated
Pneumonia(VAP)
Lumen in the
supraglotticregion
allows suctioning and
thereby reduce
aspiration.
Silver impregnation of
PVC tubes

43. Double Lumen Tubes

44. Bronchial Blockers
Univent Tube
Arndt wire guided
endobronchial blocker
Single lumen ETT with
movable bronchial
blocker in the second
lumen
Used when long term
post op ventilation is
needed

45. Intubating Aids
Direct laryngoscopes
Gum elastic bougie
Flexible fibre optic bronchoscopes
Intubating laryngeal mask airway (Fastrach)
Light wand
Video laryngoscopes
Indirect fibreoptic laryngoscopes(Bullard)

46. Direct Laryngoscopes
First introduced by
Alfred Kirstein in 1895
Jackson used it for
intubation and
modified it with distal
light source
Janeway introduced
batteries and made it
portable

47. Various Blades of Laryngoscopes

48. Gum elastic Bougie
Flexible
Narrow diameter
tracheal tube introducer
or exchanger
Length is approximately
60cm and the distal tip
can be curved or straight
Pediatric and adult sizes
available

49. Video Laryngoscopes

50. ILMA & LMA C Trach
Allows intubation with
minimal head and neck
manipulation
Recommended in both
difficult airway and
Resuscitation algorithm
C Trachallows intubation
under direct vision

51. Flexible fibreoptic bronchoscopy
Used for either
diagnostic or
therapeutic procedures
Used often in difficult
airway situation
Blood or secretion in
the airway can make
the procedure difficult

52. Light wand and intubating
Stylet
Used in anticipated
difficult intubation
Trans illumination of
anterior neck used as a
guide
Well circumscribed glow
indicates laryngeal
placement
Used both in awake and
anaesthetized patients

53. Indirect Fibre optic laryngoscope-
Bullard
Rigid fibreoptic
laryngoscope
Adult and paediatric
scopes
Difficult intubation
Multifunctional stylet
Minimal head
manipulation

54. Case Scenario
40 year old -180 kg man with history of sleep
apnoea and EF 25% has Strept .pneumonia
in his left lower lobe and progressive resp
insufficency
O/E he has 50degree neck extension and
Mallampati 2
How will you proceed?

55. Patient airway anatomy is not suggestive of
difficulty.
Supine position –subcutaneous tissues may
impair your ability to ventilate
Use reverse Trendlenburg position, shoulder
roll to make ventilation better-gravity
Have some accessory airway equipment
ready –like fibreoptic , ILMA , LMA

56. Difficult airway algorithm

57. Conclusion
Wide variety of airway armamentarium available
Provides great margin of safety
Ask for senior help early
Always have plan B and plan C available in case
plan A fails in difficult airway situations

58. Thank you