Principles of Airway Management€¦ · Principles of Airway Management was first published. A lot...

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Principles of Airway Management

Brendan T. Finucane Ban C.H. Tsui Albert H. Santora

Fourth Edition

Brendan T. Finucane ● Ban C.H. TsuiAlbert H. Santora


ISBN 978-0-387-09557-8 e-ISBN 978-0-387-09558-5DOI 10.1007/978-0-387-09558-5Springer New York Dordrecht Heidelberg London

© Springer Science+Business Media, LLC 2011All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden.The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Cover illustration: Figures 1.1-1.26, 2.2, 2.7, 2.8, 2.13, 3.2, 3.11, 9.6, 9.7, 10.1, 10.5 and 15.3-15.6 were redrawn by Alice Y. Chen (www.aliceychen.com). Figures 2.9, 3.3-3.8, 3.12-3.17, 10.3 and 10.9 were also colorized by the artist.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Brendan T. Finucane, MBBCh, FRCPCProfessor EmeritusDepartment of Anesthesiology and Pain MedicineUniversity of AlbertaDirector of Anesthesia Services Cross Cancer InstituteEdmonton, Alberta, CanadaStaff Anesthesiologist Leduc Community HospitalLeduc, Alberta, Canada

Albert H. Santora, MDAthens, GA USA

Ban C.H. Tsui, Dip Eng, BSc(Math), B Pharm, MD, MSc, FRCPC ProfessorDepartment of Anesthesiology and Pain MedicineDirector, Regional Anesthesia and Acute Pain Service Stollery Children’s Hospital University of Alberta Hospital Edmonton, Alberta, Canada

We would like to dedicate this edition of the book to our patients, our teachers, our students and our families. Dr. Tsui would especially like to express his deepest appre-ciation of the great encouragement provided to him during his academic career by his father, Woon-Tak Tsui, whom he lost suddenly during the preparation of this edition.Finally, we dedicate this book to the memory of Dr. Andranik Ovassapian (1936 – 2010) who pioneered the use of the flexible fiberop-tic bronchoscope, establishing the instrument as a fundamental airway management device. He taught thousands of practitioners how to perform fiberoptically guided tra-cheal intubation. His contributions to the field of airway management were abundant and revolutionary including the founding of the Society for Airway Management in 1995. Dr. Ovassapian was the model academician: a physician, teacher, researcher, writer, pioneer, and gentleman.

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By the time this edition is published, close to 23 years will have passed since Principles of Airway Management was first published. A lot of water has passed under the bridge since 1988. Airway groups have been formed in many countries. Several books on the topic of airway management have been published. We now have several algorithms to choose from when confronted with airway challenges. A vast array of airway devices have been invented and the number of publications on airway-related topics has increased exponentially. In 1988, none of us believed that laryngoscopy and endotracheal intubation would be obsolete in 25 years, and of course we were correct. However, that may not be true 25 years from now, and the discussions about that issue are already taking place.

We have seen a decrease in the incidence of airway tragedies in the United States in recent years, judging by the declining number of Closed Claims cases involving the airway. Perhaps this decline occurred because we have better equipment and better ways of detecting and managing airway problems. Perhaps the introduction of the LMA and other supraglottic devices has had some influence on these num-bers. However, despite the advances we have made, we continue to have our prob-lems, and there is no room for complacency.

When we first published this book, our intended audience was medical students. We have since expanded the scope of the book to provide a reference for a much broader readership. This book should now appeal to any physician or nonphysician who has a primary interest in airway management.

What is so special about this edition? We have made a number of changes, many of which were based on the critiques of the previous edition. Most of the illustra-tions in this edition have been redrawn and are in color. We have also added two new chapters, making this edition more comprehensive. This edition will also be presented in both hard and soft cover. Last, but not the least, we have recruited Ban Tsui MD, a known expert in pediatric airway management, to join us as a new coauthor and share with us his knowledge of the airway.

Each of the three authors has written five chapters of the book. Below is a summary of how each author contributed to enhance this edition. Dr. Finucane updated the opening chapters entitled “Anatomy of the Airway and Evaluation of the Airway,” to both of which he added new and colorized illustrations and improved content. Dr. Finucane also wrote the chapters on “Indications and

Preface

viii Preface

Preparation,” and “Techniques of Intubation,” and finally he wrote the closing chapter, entitled “Complications of Airway Management,” which includes statis-tics on airway complications from around the world. All of these chapters were rewritten in some fashion, have many new illustrations, and have updated bibliographies.

Dr. Tsui wrote the chapters on “Basic Emergency Airway Management and Cardiopulmonary Resuscitation (CPR)” and “Basic Airway Equipment,” incorpo-rating many components of the previous edition, but placing stronger emphasis on the importance of bag/valve/mask ventilation technique and maintaining sterility of equipment. Dr. Tsui also wrote the chapter on “Advanced Airway Devices.” In that chapter he provides a comprehensive overview, using the most up-to-date informa-tion on numerous airway devices now available for use, embellishing his descrip-tions with numerous illustrations. For “The Difficult Airway” chapter, Dr. Tsui not only updated the practice guidelines from the American Society of Anesthesiologists, but also greatly expanded the scope of the chapter to discuss the circumstances and management of the difficult airway in the emergency room, the intensive care unit, and the operating room. He also stresses the importance of airway management in obese patients and in those with obstructive sleep apnea syndrome. Finally, Dr. Tsui has completed a major revision of the chapter dedicated to “Pediatric Airway Management.” He divided this chapter into two sections A and B. In section A, Dr. Tsui updated information from the previous edition on basic and advanced airway management in the child and added some information on intubation trauma and the use of heliox in pediatric airway management. Dr. Tsui also discusses the important interplay between the larynx, the pharynx, and the tongue in pediatric airway obstruction. For section B, Dr. Tsui invited Dr. Hamdy El-Hakim [MD, FRCS(ORL-HNS), Divisions of Otolaryngology and Pediatric Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada] as a primary author to share his expertise on surgical aspects of pediatric airway management. Drs. Tsui and El-Hakim highlight important considerations for the anesthesiologist and sur-geon during otolaryngological (primarily endoscopic) procedures. We are grateful for Dr. El-Hakim’s important contribution to this chapter. This contribution by Dr. El-Hakim is an excellent example of the importance of collaboration between anesthesiologists and surgeons when dealing with some of the most challenging airway issues in medicine

Dr. Santora updated chapters on “Fibroptically Guided Airway Intubation Techniques,” “Mechanical Ventilation and Respiratory Care,” and the “Surgical Options in Airway Management.” A new chapter, “Extubation Strategies: The Extubation Algorithm,” addresses an area of airway management hitherto relegated to secondary concern. Finally, the chapter entitled “The Laryngeal Mask Airway (LMA™) and other Extraglottic (Supraglottic) Airway Devices” summarizes many new considerations of this revolutionary airway tool. To address valid criticisms leveled at this chapter in the 3rd Edition, extensive thought has been given to the question: Is the extraglottic airway device interchangeable with the endotracheal tube in the practice of anesthesia?

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It is evident that we have completed a major revision of Principles of Airway Management and have every hope that this edition represents the most up-to-date information on this rapidly advancing discipline.

Edmonton, AB Brendan T. FinucaneEdmonton, AB Ban C.H. TsuiAthens, GA Albert H. Santora

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The authors wish to acknowledge Donna Finucane’s valuable contribution as we prepared to submit the final edition to the Publisher. We would also like to give credit to Jennifer Pillay for her contributions towards editing a portion of this book. We would also like to thank Brian Belval for helping us get started and Catherine Paduani for helping us finish this important edition. We are grateful to Portia Bridges for centrally coordinating all aspects of this work at a very early stage. We would like to thank the graphic artist Alice Chen for her excellent drawings and for the color version of some of our old drawings. Adam Dryden helped by taking many of the pictures of equipment and devices, and Nicole Stalker helped obtain numerous images for the Advanced Airway Devices chapter. Finally, we would like to acknowledge Jenkin Tsui’s drawings which helped the graphic artist interpret what was required in some of the illustrations.

Acknowledgements

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1 Anatomy of the Airway ............................................................................ 1Introduction ................................................................................................. 2The Nose ..................................................................................................... 2Oral Cavity .................................................................................................. 4

Uvula ...................................................................................................... 4Tonsils ..................................................................................................... 5Tongue .................................................................................................... 6

Pharynx ....................................................................................................... 7Prevertebral Fascia .................................................................................. 9Retropharyngeal Space ........................................................................... 9

Larynx ......................................................................................................... 10Laryngeal Cartilages ............................................................................... 11Laryngeal Cavity .................................................................................... 15Nerve Supply to the Larynx .................................................................... 16Action of the Cricothyroid Muscle and the Intrinsic Muscles of the Larynx .......................................................................................... 17

Trachea and Bronchi ................................................................................... 18Main Divisions of the Bronchial Tree .................................................... 20

Comparative Anatomy of the Adult and Infant Airways ............................ 21Head ........................................................................................................ 22Nose ........................................................................................................ 22Tongue .................................................................................................... 22Larynx ..................................................................................................... 22Cricoid Cartilage .................................................................................... 23Epiglottis ................................................................................................. 23Trachea and Mainstem Bronchi .............................................................. 23

Summary ..................................................................................................... 25References ................................................................................................... 25Suggested Reading ...................................................................................... 25

Contents

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2 Evaluation of the Airway .......................................................................... 27Introduction ................................................................................................. 28The Normal/Abnormal Airway ................................................................... 29Predictive Tests for Difficult Intubation ...................................................... 29Elective Intubation ...................................................................................... 32

History Pertinent to Elective Airway Management ................................ 32Diabetes Mellitus .................................................................................... 32NPO Status ............................................................................................. 33Physical Examination ............................................................................. 34

Structured Approach ................................................................................... 49Bag/Valve/Mask Ventilation ....................................................................... 50Additional Information ............................................................................... 52

Arterial Blood Gases .............................................................................. 52ENT Consultation ................................................................................... 53Radiologic Studies .................................................................................. 53Pulmonary Function Studies ................................................................... 53Flow-Volume Loops ............................................................................... 54Difficult Airway Clinic ........................................................................... 54The “Awake Look” ................................................................................. 55


3 Basic Emergency Airway Management and Cardiopulmonary Resuscitation (CPR) .......................................... 59Emergency Airway Management ................................................................ 60Importance of Basic Life Support ............................................................... 60Adult Basic Life Support (BLS) ................................................................. 61

Chain of Survival .................................................................................... 62Changes in the 2005 and 2010 AHA Recommendations ....................... 62The AHA Algorithm and Recommendations for Rescue Breaths, a Universal Compression-Ventilation Ratio, and Defibrillation ............. 63Techniques of CPR ................................................................................. 68Limitations and Complications of CPR .................................................. 80

Airway Obstruction ..................................................................................... 80Etiology of Upper Airway Obstruction .................................................. 80The Tongue as a Cause of Airway Obstruction ...................................... 81Foreign Body Airway Obstruction ......................................................... 82

CPR and Precautions Against the Transmission of Disease ....................... 87Transmission of Disease from CPR Mannequins ................................... 88

Summary ..................................................................................................... 89References ................................................................................................... 89

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4 Basic Equipment for Airway Management ............................................ 93Introduction ................................................................................................. 93Oxygen Sources .......................................................................................... 94

Wall Oxygen ........................................................................................... 94Tank Oxygen ........................................................................................... 95Pulse Oximetry and Capnography .......................................................... 98

Vacuum Suction Apparatus ......................................................................... 98Oxygen Delivery Systems for Spontaneously Breathing Patients .............. 100Oxygenation and Ventilation Systems ........................................................ 104

Airways ................................................................................................... 105Anesthesia Masks and Resuscitation Bags ............................................. 110Equipment for Endotracheal Intubation ................................................. 115Other Useful Airway Tools ..................................................................... 121

Cleaning, Disinfecting, and Sterilizing Equipment .................................... 121Equipment Problems .............................................................................. 123

“The Dedicated Airway” and the “Ideal Airway Device” .......................... 124Summary ..................................................................................................... 124References ................................................................................................... 124

5 The Laryngeal Mask Airway (LMA™) and Other Extraglottic (Supraglottic) Airway Devices ............................................ 129Introduction ................................................................................................. 130The “Ideal” Extraglottic Airway ................................................................. 131Classification of Extraglottic (Supraglottic) Airway Devices .................... 132

Description of Extraglottic Airways ....................................................... 133Basic Extraglottic Airway Design and Function .................................... 133Cleaning and Sterilization of Reusable LMA™ Products ...................... 135Basic LMA™ Design Features ............................................................... 135LMA™ Models ...................................................................................... 137Ambu® Line of Extraglottic Airway Products ........................................ 137General Information Concerning Ambu® LMAs .................................... 137Sizing of Extraglottic Airways ............................................................... 139Descriptions of Extraglottic Airway Design and Features ..................... 139Illustrations of Extraglottic Airway Devices .......................................... 139

Insertion Techniques ................................................................................... 153Preinsertion Recommendations .............................................................. 153LMA™ Insertion Recommendations ..................................................... 153LMA™ Insertion .................................................................................... 154Index Finger Insertion Technique ........................................................... 155Thumb Insertion Technique .................................................................... 157LMA ProSeal™ Insertion Using the Introducer ..................................... 159Testing the LMA ProSeal™ for Proper Positioning: “Malpositioning Test”............................................................................. 163LMA Fastrach™ Insertion and Intubation Through the Airway ............ 170Insertion of Ambu® Mask Airways ........................................................ 178

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Insertion of the SLIPA™ SGA ............................................................... 182Insertion of SLIPA™ Airway ................................................................. 184Insertion of the King LT(S)-D® Airway ................................................. 186Modified Insertion Techniques ............................................................... 187Use of the GEB (Gum Elastic Bougie) for LMA ProSeal ™ Insertion ................................................................................ 188Laryngoscope-Guided, GEB-Guided LMA ProSeal™ Insertion Technique ................................................................................ 190

Removing the Extraglottic Airway ............................................................. 193Further Comments on LMA™ Size ............................................................ 194Ease of LMA™ Insertion and Airway Grading Systems ........................... 194Comparison of Methods to Assess LMA™ Airway Sealing Pressures ...... 195LMA™ and Modalities of Ventilation ........................................................ 196Use of the LMA™ with Pediatric Patients ................................................. 197

Insertion Techniques for Pediatric Patients ............................................ 197Removal of the LMA™ in Pediatric Patients ......................................... 198Use of the LMA™ to Manage Patients with Congenital Airway Anomalies .................................................................................. 198LMA™ and Neonatal Resuscitation ....................................................... 199Diagnostic Fiberoptic Bronchoscopy with LMA™ Assistance ............. 199Use of the LMA™ in Pediatric Surgical Patients with Upper Respiratory Tract Infections (URI’s) and Mild Bronchopulmonary Dysplasia (BPD) ..................................................... 199The Learning Curve for Use of the LMA™ on Pediatric Patients ......... 201Long-Term Use of the LMA™ on Pediatric Patients ............................. 201The Use of the LMA ProSeal™ on Pediatric Patients ........................... 201

Innovative Uses of the LMA™ ................................................................... 202Patient Position ....................................................................................... 203

Adjunctive Equipment to Aid Endotracheal Intubation Through the Extraglottic Airway ............................................................................... 205Extraglottic Airways and the “Difficult Airway” ....................................... 205

Use of the LMA™ to Manage the Difficult Airway in Obstetric Patients ................................................................................ 208Use of the LMA™ and the Difficult Pediatric Airway .......................... 209The LMA™ and the Morbidly Obese Patient ........................................ 210Use of the LMA™ in Patients with Cervical Spine Pathology .............. 210Cervical Pressure and Movement Associated with LMA™ Use ........... 211

Role of the LMA Outside of the Operating Room (PreHospital and Emergency Room) ................................................................................ 212Problems Associated with the Use of Extraglottic Airway Devices ........... 213What to Do if the Patient Regurgitates with an Extraglottic Airway in Place ........................................................................................... 215U.S. FDA Regulations Concerning the Introduction of Extraglottic Airway Devices to the Market: “510 (k) Exempt” Classification ............................................................................................... 216

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Is the Extraglottic Airway Device Interchangeable with the Endotracheal Tube in the Practice of Anesthesia? ...................................... 217Summary ..................................................................................................... 223References ................................................................................................... 223

6 Advanced Airway Devices ........................................................................ 233Introduction ................................................................................................. 234Supra and Infraglottic Devices .................................................................... 235

Supraglottic Devices ............................................................................... 235Infraglottic Devices ................................................................................ 245

Laryngoscope Handles and Blades ............................................................. 247Handles ................................................................................................... 247Blades ..................................................................................................... 249

Fiberoptic Laryngoscopes ........................................................................... 254Truview EVO2 ........................................................................................ 254Heine FlexTip+ ....................................................................................... 255Flipper ..................................................................................................... 255Bullard .................................................................................................... 257WuScope ................................................................................................. 257

Video Laryngoscopes .................................................................................. 258Storz DCI Video Intubating System ....................................................... 259GlideScope ............................................................................................. 260McGrath .................................................................................................. 263Airway Scope (AWS-S100) .................................................................... 265Airtraq ..................................................................................................... 266TrachView Intubating Videoscope .......................................................... 268Comparisons of Indirect Laryngoscopes ................................................ 269

Stylets and Light Wands ............................................................................. 269Conventional Stylets: Endotracheal Tube Introducers and Exchangers ....................................................................................... 269Optical Stylets ........................................................................................ 272Illuminating Stylets (Lightwands) .......................................................... 278

Endotracheal Tubes ..................................................................................... 281Articulating ............................................................................................. 281Armored or Wire-Reinforced ................................................................. 282Double-Lumen Endobronchial ............................................................... 282Polar RAE (Ring-Adair-Elwyn) ............................................................. 283Uncuffed ................................................................................................. 284Parker Flex-Tip ....................................................................................... 284GlideRite ................................................................................................. 285Brief Review of Other Tubes .................................................................. 285

Cricothyrotomy ........................................................................................... 286Catheter-Over-Needle Technique ........................................................... 286Wire-Guided Technique .......................................................................... 287

Ultrasound Imaging of the Airway ............................................................. 289

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Oral Cavity and Pharynx ........................................................................ 290Larynx ..................................................................................................... 291Cervical Trachea ..................................................................................... 291Lung ........................................................................................................ 292Available Portable Ultrasound Systems .................................................. 292

Airway Management Training Devices ...................................................... 293Task/Skills Trainers ................................................................................ 293Manikins and Simulated Settings ........................................................... 294Animal Models ....................................................................................... 296Cadaver Models ...................................................................................... 296Virtual Reality Simulators ...................................................................... 296

References ................................................................................................... 297

7 Indications and Preparation of the Patient for Intubation ................... 309Introduction ................................................................................................. 310General Indications for Intubation .............................................................. 310

Ventilatory Support ................................................................................. 310Selecting the Route of Intubation ............................................................... 317

Orotracheal Intubation ............................................................................ 317Nasotracheal Intubation .......................................................................... 318Transtracheal Intubation ......................................................................... 319Endobronchial Intubation ....................................................................... 319

Preparation of the Patient for Intubation Outside the Operating Room ...................................................................... 319

Patient Interview ..................................................................................... 320Sedation .................................................................................................. 320Local Anesthetic Techniques .................................................................. 322General Anesthesia ................................................................................. 322

Neuromuscular Blocking Drugs ................................................................. 323Depolarizing Drug: Succinylcholine ...................................................... 324Nondepolarizing Drugs .......................................................................... 326Methods of Administering a Neuromuscular Blocking Drug ................ 327Reversal of Neuromuscular Blockade .................................................... 327


8 Techniques of Intubation .......................................................................... 331Introduction ................................................................................................. 332Intubation Methods ..................................................................................... 333

Orotracheal Intubation by Direct Vision in an Adult (Macintosh Blade) ............................................................... 333Orotracheal Intubation by Direct Vision in an Adult (Miller Blade) .......................................................................... 349

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Nasotracheal Intubation by Direct Vision in an Adult (Macintosh Blade) .................................................................. 349

Airway Maneuvers .................................................................................... 356BURP .................................................................................................... 357OELM ................................................................................................... 357Sellick’s Maneuver (Cricoid Pressure) ................................................. 357

Failed Intubation (Normal Anatomy) ....................................................... 358Summary ................................................................................................... 358References ................................................................................................. 359Suggested Reading .................................................................................... 360

9 The Difficult Airway ............................................................................... 361Introduction ............................................................................................... 362Definitions ................................................................................................. 362Mask Ventilation ....................................................................................... 364Incidence of the Difficult Airway ............................................................. 365Etiology of Difficult Intubation ................................................................ 370

Limited Access to the Oropharynx or Nasopharynx ............................. 370Inability to See the Larynx .................................................................... 370Diminished Cross-Sectional Area of the Larynx or Trachea ................ 370

Practice Guidelines and the ASA Difficult Airway Algorithm ................ 371Difficult Airway Kit .................................................................................. 374

Basic Essentials of an Airway Kit ........................................................ 374Structured Approach to the Difficult Airway in the Operative Room ...... 374

Failed Awake Intubation for Elective Surgery ...................................... 375Unanticipated Difficult Airway in Elective Surgery ............................. 376Unanticipated Difficult Intubation in Emergency Surgery ................... 378Anticipated Difficulty in Elective or Emergency Surgery .................... 379

Loss of the Airway: “Cannot Intubate, Cannot Ventilate” ........................ 379Difficult Airway in Special Circumstances ............................................... 381

Emergency Room .................................................................................. 381Intensive Care Unit (ICU) ..................................................................... 393Operating Room .................................................................................... 395

Summary ................................................................................................... 406References ................................................................................................. 407

10 Pediatric Airway Management .............................................................. 417Section A: Basic and Difficult Airway Management ............................... 417Introduction ............................................................................................... 417The Pediatric Airway: Anatomy and Function ......................................... 417

Susceptibility to Obstruction................................................................. 417Susceptibility to Respiratory Failure .................................................... 420Difficulty During Tracheal Intubation .................................................. 421

Basic Airway Management and CPR in Infants and Children.................. 421Opening the Airway .............................................................................. 422

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Basic Life Support ................................................................................ 423Resuscitation of the Neonate .................................................................... 426

2005 and 2010 American Heart Association Neonatal Resuscitation Guidelines ....................................................................... 428The Neonatal Resuscitation Program .................................................... 431

Airway Equipment .................................................................................... 433Face Masks ............................................................................................ 433Airways ................................................................................................. 433Laryngeal Mask Airway (LMA) and Other Supraglottic Devices ........ 434T-Piece .................................................................................................. 435Intubation Equipment ............................................................................ 436

Techniques For Bag-Valve-Mask Ventilation ........................................... 439Techniques of Routine Endotracheal Intubation in Infants and Children .................................................................................. 439

Premedication and Induction of Anesthesia ......................................... 440Position ................................................................................................. 440Confirmation ......................................................................................... 441Stabilization and Monitoring ................................................................ 442Summary ............................................................................................... 442

Laryngospasm ........................................................................................... 442Intubation Trauma ..................................................................................... 444Difficult Pediatric Airway ......................................................................... 445

Definition and Classifications ............................................................... 445Anesthetic Management and Induction Technique ............................... 448Clinical Strategies for Difficult Ventilation and Intubation .................. 449Fiberoptic Intubation Techniques ......................................................... 451Extubation Considerations for the Difficult Airway ............................. 452

Airway Obstruction in the Child ............................................................... 453Clinical Presentation ............................................................................. 453Etiology ................................................................................................. 454Managing Foreign Body Airway Obstruction (FBAO) ........................ 464Treating Epiglottitis and Croup ............................................................. 469Management of the Child with Impending Complete Airway Obstruction .............................................................. 472

Heliox in Pediatric Airway Management ................................................. 474Tracheostomy in the Child ........................................................................ 474

Preparation ............................................................................................ 475Technique .............................................................................................. 475Complications ....................................................................................... 475

Summary ................................................................................................... 476Section B: Advanced Airway Management for Endoscopic (ENT) Procedures ..................................................................................... 477Introduction ............................................................................................... 477Description of Basic Endoscopic Procedures ........................................... 477

Flexible Endoscopy ............................................................................... 477

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Rigid Bronchoscopy .............................................................................. 478Microlaryngoscopy ............................................................................... 479

Anesthetic Considerations for Endoscopic Procedures ............................ 479Goals of the Anesthesiologist during Pediatric ENT Procedures ......... 480General Anesthetic Approaches ............................................................ 481Anesthetic Options During the Airway Procedure ............................... 483

Clinical Scenarios ..................................................................................... 487Upper Airway Pathology ...................................................................... 488Lower Airway Pathology ...................................................................... 500

References ................................................................................................. 506

11 Fiberoptically Guided Airway Management Techniques .................... 515Introduction ............................................................................................... 516Applications .............................................................................................. 516Implementation: Learning the Technique ................................................. 517Indications ................................................................................................. 518Equipment ................................................................................................. 519

Intubating Airways ................................................................................ 519Masks/Adapters ..................................................................................... 521Endotracheal Tubes ............................................................................... 522Light Source .......................................................................................... 523Fiberoptic Endoscope ............................................................................ 525Fiberoptic Cart ...................................................................................... 527

Techniques of Fiberoptic Intubation ......................................................... 529Awake Fiberoptic Intubation ................................................................. 530Fiberoptic Intubation for an Anesthetized Patient ................................ 548

Difficulty Passing the Endotracheal Tube Off the Fiberoptic Scope: Causes and Solutions ................................................................................ 550

Right Arytenoid Cartilage Impediment to Endotracheal Tube Passage over Endoscope .............................................................. 550Rotation of the Endotracheal Tube ....................................................... 551Alternate Endotracheal Tube Tip Designs ............................................ 551Tube Size and Fiberoptic Scope Diameter ............................................ 552Conclusions ........................................................................................... 553

Complications of Fiberoptic Intubation .................................................... 553Special Uses of the Fiberoptic Endoscope ................................................ 554

Endobronchial Tube Placement ............................................................ 555Retrograde Wire-Guided Intubation ..................................................... 555Endotracheal Tube Change ................................................................... 556

Case Report ............................................................................................... 556Techniques to use in the ICU .................................................................... 557Pediatric Use ............................................................................................. 558Fiberoptic Endoscopy and Adjunctive Airway Devices ........................... 558

COPA (Cuffed Oropharyngeal Airway) ................................................ 558LMA (Laryngeal Mask Airway) ........................................................... 559

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Other Devices ........................................................................................ 559Fiberoptic Endoscope and Jet Ventilation ................................................. 561Fiberoptic Endoscopy in the Difficult/Emergent Airway Scenario .......... 561Optical Intubating Stylets ......................................................................... 562Summary ................................................................................................... 563References ................................................................................................. 563

12 Surgical Options in Airway Management ............................................ 569Introduction ............................................................................................... 570Oxygenation vs. Ventilation ...................................................................... 570Airway Algorithms ................................................................................... 571Preparing to Manage the Surgical Airway ................................................ 571Surgical Options in Airway Management ................................................. 572Techniques ................................................................................................ 572

Needle/Catheter Cricothyroidotomy ..................................................... 573Retrograde Catheter-Assisted Intubation .............................................. 584Minitracheostomy ................................................................................. 588Percutaneous Dilational Tracheostomy (PDT) ..................................... 594Adjunctive Equipment and Techniques Used to Facilitate PDT Placement and other Surgical Airway Management Options ....... 613Learning Percutaneous Tracheostomy .................................................. 621Clinical Patterns of PDT Utilization ..................................................... 621Teaching Surgical Airway Techniques .................................................. 622Contraindications to Performing Percutaneous Tracheostomy ............. 622Emergency Percutaneous Tracheostomy .............................................. 623Emergency Surgical Cricothyrotomy .................................................... 623Emergency Cricothyroidotomy Techniques .......................................... 627Formal Tracheostomy ........................................................................... 631Rigid Bronchoscopy .............................................................................. 632


13 Mechanical Ventilation and Respiratory Care ..................................... 641Introduction ............................................................................................... 642Description of a Mechanical Ventilator .................................................... 643Commonly Utilized Modes of Ventilation ................................................ 643

Siemens Servo Ventilator ...................................................................... 644Initial Ventilator Settings ...................................................................... 646Pediatric and Neonatal Ventilation ........................................................ 647Weaning the Patient from Mechanical Ventilation ............................... 649

Troubleshooting Ventilator Problems ....................................................... 650Current Strategies and Practices in Mechanical Ventilation and Respiratory Care ................................................................................. 651

ALI/ARDS (Acute Lung Injury/Acute Respiratory Distress Syndrome) ............................................................................... 653

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Current Ventilation Strategies ............................................................... 655Recruitment Maneuvers ........................................................................ 656Alternative Modalities of Ventilation .................................................... 658New Weaning Strategies ....................................................................... 658

Complications of Mechanical Ventilation ................................................. 659Ventilator Associated Pneumonia ......................................................... 660Closed-Circuit Suctioning ..................................................................... 661Portable Ventilators ............................................................................... 661Hyperbaric Oxygenation ....................................................................... 662Ethical Considerations of Mechanical Ventilation ................................ 662

Future ALI/ARDS Research ..................................................................... 662Summary ................................................................................................... 662References ................................................................................................. 663

14 Extubation Strategies: The Extubation Algorithm .............................. 667Introduction ............................................................................................... 667Purpose of an Algorithm ........................................................................... 668

Purpose of an Extubation Algorithm .................................................... 668Extubation Criteria ................................................................................ 668Extubation Criteria Following a Difficult Intubation ............................ 669

Strategies to Extubate a Patient with a Difficult Airway .......................... 670American Society of Anesthesiologists Task Force on the Management of the Difficult Airway: Strategy for Extubation of the Difficult Airway .................................................. 670Difficult Airway Extubation Algorithms .............................................. 671Hagberg et al. Extubation Algorithm .................................................... 671Extubation Algorithm for Patients with Difficult Airways ................................................................................................. 673Preoxygenation ..................................................................................... 673Airway Anesthesia Prior to Extubation ................................................ 673Patient Education Prior to Extubation ................................................... 674Option A: Extubation over an Airway Guide ....................................... 675Option B: Extubation with Fiberoptic Guidance .................................. 675Option C: Extubation with Video Laryngoscopic Guidance ................ 677Combined Extubation Options .............................................................. 679


15 Complications of Airway Management ................................................ 683Introduction ............................................................................................... 685Complications Arising During Intubation ................................................ 685

Trauma .................................................................................................. 685Hypoxemia ............................................................................................ 689

Complications Arising Immediately After Intubation .............................. 695Hypoxemia ............................................................................................ 695

xxiv Contents

Complications Arising upon Removal of Endotracheal Tube .................. 701Hypoxemia ............................................................................................ 701Sore Throat ............................................................................................ 705Temporomandibular Joint Dysfunction ................................................ 706Vocal Cord Injury .................................................................................. 706Neural Injury ......................................................................................... 708

Complications Arising from Long-Term Intubation ................................. 709Ulceration of the Mouth, Pharynx, Larynx, and Trachea ..................... 710Granuloma Formation ........................................................................... 710Formation of Synechiae and Webs ........................................................ 710Tracheal Stenosis .................................................................................. 710

Complications Occurring Specifically in Relation to Nasotracheal Intubation ............................................................................ 711

Epistaxis ................................................................................................ 711Submucosal Dissection ......................................................................... 711Middle Turbinectomy............................................................................ 711Trauma to the Posterior Pharyngeal Wall ............................................. 712Trauma to the Adenoids ........................................................................ 712Pressure Necrosis in the Nose ............................................................... 712Obstruction of the Eustachian Tube ...................................................... 712Maxillary Sinusitis ................................................................................ 712

Complications of Laser Surgery ............................................................... 712Summary ................................................................................................... 713Airway Management Complications Summarized from Anesthesiology Morbidity Studies ................................................... 713

American Society of Anesthesiologists Closed Claims Study ............. 714Australian Incident Monitoring Study (AIMS) ..................................... 718Deaths Attributed to Anesthesia in New South Wales: 1984–1990............................................................................................. 722The Pediatric Perioperative Cardiac Arrest Registry (POCA) .............. 723NCEPOD (National Confidential Enquiry into Perioperative Deaths) ............................................................................ 723SAMS (Scottish Audit of Surgical Mortality) ...................................... 725Danish Morbidity Study: 1994–1998.................................................... 725

Summary ................................................................................................... 727References ................................................................................................. 727Suggested Reading .................................................................................... 730

Index ................................................................................................................. 731

1B.T. Finucane et al., Principles of Airway Management, DOI 10.1007/978-0-387-09558-5_1, © Springer Science+Business Media, LLC 2011

Chapter 1Anatomy of the Airway

Contents

Introduction ............................................................................................................................. 2The Nose ................................................................................................................................. 2Oral Cavity .............................................................................................................................. 4

Uvula .................................................................................................................................. 4Tonsils ................................................................................................................................ 5Tongue ................................................................................................................................ 6

Nerve Supply to the Tongue .......................................................................................... 6Pharynx ................................................................................................................................... 7

Prevertebral Fascia ............................................................................................................. 9Retropharyngeal Space ....................................................................................................... 9

Larynx ..................................................................................................................................... 10Laryngeal Cartilages .......................................................................................................... 11

Single Cartilages ............................................................................................................ 11The Paired Cartilages..................................................................................................... 13

Laryngeal Cavity ................................................................................................................ 15Piriform Sinus (Recess or Fossa)................................................................................... 15

Nerve Supply to the Larynx ............................................................................................... 16Superior Laryngeal Nerve ............................................................................................. 16Recurrent Laryngeal Nerve ........................................................................................... 16

Action of the Cricothyroid Muscle and the Intrinsic Muscles of the Larynx .................... 17Trachea and Bronchi ............................................................................................................... 18

Main Divisions of the Bronchial Tree ................................................................................ 20Comparative Anatomy of the Adult and Infant Airways ........................................................ 21

Head ................................................................................................................................... 22Nose ................................................................................................................................... 22Tongue ................................................................................................................................ 22Larynx ................................................................................................................................ 22Cricoid Cartilage ................................................................................................................ 23Epiglottis ............................................................................................................................ 23Trachea and Mainstem Bronchi ......................................................................................... 23

Summary ................................................................................................................................. 25References ............................................................................................................................... 25Suggested Reading .................................................................................................................. 25

2 1 Anatomy of the Airway

Introduction

Knowledge of anatomy is essential to the study of airway management. First, anatomical considerations are helpful in diagnosing certain problems, such as the position of a foreign body in a patient with airway obstruction. Second, since some procedures involved in establishing and maintaining an airway are performed under emergency conditions, little if any time may be available for reviewing anatomy. Third, in many procedures involving the airway, such as tracheal intubation, ana-tomical structures are only partially visible. As a result, one must recognize not only the structures in view but also their spatial relationship to the surrounding structures. This chapter reviews basic airway anatomy, discusses some clinical corre-lates, and includes a comparison of the pediatric and adult airway.

The Nose

The nose is a pyramidal-shaped structure projecting from the midface made up of bone, cartilage, fibrofatty tissue, mucous membrane, and skin. It contains the peripheral organ of smell and is the proximal portion of the respiratory tract. The nose is divided into right and left nasal cavities by the nasal septum. The inferior portion of the nose contains two apertures called the anterior nares. Each naris is bounded laterally by an ala, or wing. The posterior portions of the nares open into the nasopharynx and are referred to as choanae. One or both of these apertures are absent in the congenital anomaly choanal atresia.1 Infants born with this condition are at risk of suffocation as they are compulsive nose breathers at birth. Urgent surgical correction of choanal atresia is required soon after birth in these cases.

The nose has a number of important functions, including: respiration, olefaction, filtration, humidification, and is a reservoir for secretions from the paranasal sinuses and the nasolacrimal ducts.

Anatomically, each side of the nose consists of a floor, a roof, and medial and lateral walls. The septum forms the medial wall of each nostril and is made up of perpendicular plates of ethmoid and vomer bones and the septal cartilage (Fig. 1.1). The bony plate forming the superior aspect of the septum is very thin and descends from the cribriform plate of the ethmoid bone. The cribriform plate may be frac-tured following trauma. Head injury victims should be questioned about nasal dis-charge, which may be cerebrospinal fluid (CSF). Nasotracheal intubation and the passage of nasogastric tubes are relatively contraindicated in the presence of basal skull fractures.2 The lateral walls have a bony framework attached to which are three bony projections referred to as conchae or turbinates (Fig. 1.2). The upper and middle conchae are derived from the medial aspect of the ethmoid; the inferior concha is a separate structure. There are a number of openings in the lateral nasal walls that communicate with the paranasal sinuses and the nasolacrimal duct.

A coronal section of the nose and mouth shows the location and relationships of the nasal structures more clearly (Fig. 1.3). Considerable damage can be inflicted

3The Nose

Fig. 1.1 The nasal septum (sagittal)

Fig. 1.2 The lateral nasal wall

4 1 Anatomy of the Airway

on the lateral walls of the nose by forcing endotracheal tubes into the nasal cavity in the presence of an obstruction.

Nasal endotracheal tubes and nasal airways should be well lubricated, and vasocon-stricting solutions should be applied to the nasal mucosa before instrumentation. When introducing a nasal endotracheal tube into the nostril, the bevel of the tube should be parallel to the nasal septum to avoid disruption of the conchae (Fig. 8.18, Chap. 8).

Oral Cavity

The mouth or oral cavity (Fig. 1.4), is divided into two parts: the vestibule and the oral cavity proper. The vestibule is the space between the lips and the cheeks exter-nally and the gums and teeth internally (see Fig. 1.3). The oral cavity proper is bounded anterolaterally by the alveolar arch, teeth, and gums; superiorly by the hard and soft palates; and inferiorly by the tongue. Posteriorly, the oral cavity com-municates with the palatal arches and pharynx.

Uvula

In the posterior aspect of the mouth, the soft palate is shaped like the letter M, with the uvula as the centerpiece. This structure is a useful landmark for practitioners assessing the ease or difficulty of mask ventilation or tracheal intubation.

Fig. 1.3 Coronal section through the nose and mouth

5Oral Cavity

Tonsils

The tonsils that we see when we look in the mouth are formally known as the palatine tonsils which are collections of lymphoid tissue engulfed by two soft tissue folds, the “pillars of the fauces.” The anterior fold is called the palato-glossal arch, and the posterior, the palatopharyngeal arch (see Fig. 1.4). However, tonsillar tissue is far more extensive than that. There is a collection of lymphoid tissue called the “tonsillar ring” which is situated in an incomplete circular ring around the pharynx. It is made up of the palatine tonsils (between the pillars of the fauces), the pharyngeal tonsil, (adenoids), tubular tonsils (which extend bilat-erally into the eustachian tubes), and the lingual tonsil (which is a collection of lymphoid tissue on the posterior aspect of the tongue). The lingual tonsil is situated behind the sulcus terminalis and has a cobblestone appearance (Fig. 1.5). Hypertrophy of the pharyngeal tonsil (adenoids) can obstruct the nasal airway, necessitating mouth breathing. Hearing may be impaired when the tubular tonsils become infected. Hypertrophy of the lingual tonsil may cause airway obstruction, difficult mask ventilation, and difficult tracheal intubation.3

Fig. 1.4 The oral cavity

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