Basic and Advanced Airway management

Basic and Advanced Airway Management  

  • Key Principles 

  • Assessment over intervention: Not all patients need intubation – avoid rushing into invasive management 
  • Systematic approach: Progress from basic to advanced techniques as needed 
  • Safety first: Always have backup plans and rescue devices ready 

LEMON Airway Assessment Method 

L – Look Externally 

  • Body habitus: Obesity, short neck 
  • Beards: May complicate mask seal
  • Midface trauma and jaw malocclusion
  • Short neck and large tongue 

E – Evaluate (3-3-2 Rule) 

    • Inter-incisor distance: Should be at least 3 fingers 
    • Hyomental distance: 3 fingers from base of mandible to hyoid bone 
    • Thyromental distance: 2 fingers from hyoid bone to thyroid notch 

M – Mallampati Classification 

Purpose: Predicts difficulty of laryngoscopy and intubation based on oropharyngeal anatomy 

Classifications: 

    • Class I: Complete visualization of soft palate, uvula, anterior and posterior pillars 
    • Class II: Visualization of soft palate, uvula, and anterior pillars 
    • Class III: Visualization of soft palate and base of uvula only 
    • Class IV: Only hard palate visible

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Clinical Significance: 

    • Class I & II: Usually easy intubation 
    • Class III: Moderate difficulty 
    • Class IV: Difficult intubation likely 

O – Obstruction 

    • Epiglottitis, head and neck cancer, Ludwig’s angina 
    • Neck hematoma, airway burn, foreign body 

N – Neck Mobility 

    • OA (occipital-atlantal joint): Rheumatoid, ankylosing spondylitis 
    • Cervical spinal immobilization 
    • Previous neck injury or surgery 

Emergency Airway Assessment 

        Rapid Clinical Assessment 

  •  Level of responsiveness
  • Skin color and respiratory effort 
  • Respiratory rate and depth 
  • Oxygen saturation and capnography (unless impending cardiac arrest) 
  • Never assess gag reflex by placing objects in pharynx 

Identifying Airway Compromise 

Conscious Patients: 

    • Typically sit upright and look distressed 
    • Examine for:  
    • Swollen tongue (angioedema/anaphylaxis) 
    • Sooty sputum (thermal injury) 
    • Neck hematomas (blunt/penetrating trauma) 

Unconscious Patients: 

    • Examine for:  
    • Snoring or added airway noises 
    • Abnormal chest/abdominal wall movement (airway obstruction) 
    • Lack of fogging on oxygen mask 
    • Suction risk: Vulnerable to aspiration of vomit, blood, secretions, foreign bodies  
    • Use wide bore rigid sucker with gentle suction under direct vision 

Airway Obstruction Classification 

Features and Signs by Location 

 

Additional Features 

    • Reduced conscious level (GCS<8) 
    • Use of accessory muscles of respiration 
    • Paradoxical chest and abdominal movement (see-saw breathing) 
    • Agitation and altered consciousness 
    • Cyanosis 

Causes by Mechanism 

Basic Airway Management 

Chin-Lift Maneuver

    • Technique:  
    • Place one hand on forehead to tilt head back gently 
    • Use fingertips of other hand under bony part of chin to lift jaw forward 
    • Avoid pressing on soft tissues under chin (can obstruct airway) 
    • Effect: Opens airway by moving tongue away from back of throat 
    • Positioning aids:  Standard patients keep Pillow/blanket under head for “sniffing position” 

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Obese patients: Pillow under shoulders + multiple pillows under head to elevate chin above chest 

Note: Beware hyperextension of the neck with the chin-lift manoeuvre because it can further compromise the airway.

Contraindication: Suspected cervical spine injury

Jaw-Thrust Maneuver

    • Technique: Lifts mandible forwards and lifts tongue off posterior pharynx 
    • Cervical spine injury: Use jaw-thrust instead of chin-lift (contraindicated to move head/neck) 

 

Suction 

    • Unconscious patients: Vulnerable to aspiration 
    • Technique: Wide bore rigid sucker with gentle suction under direct vision 
    • Goal: Remove vomit, blood, secretions, foreign bodies 

Airway Adjuncts 

Basic Airways (Unconscious Patients Only) 

Oropharyngeal Airway (OPA)

    • Sizing: Measure from patient’s incisors to angle of jaw 
    • Insertion: Insert “upside down,” twist 180° once inserted halfway (behind tongue) 
    • Position: Flanged front end should sit just in front of teeth 
    • Complications: May cause vomiting or laryngospasm – remove promptly if occurs

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Nasopharyngeal Airway (NPA)

    • Use: Patients with difficult mouth opening (seizures) 
    • Sizing: Internal diameter marked on tube – 6mm for women, 7mm for men 

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    • Procedure:  
    • Lubricate with gel 
    • Insert into nostril gently curved side down 
    • Aim towards occiput 
    • Use twisting motion if necessary 
    • Change to smaller airway if firm resistance
    • Complications: Nasal hemorrhage 
    • Contraindication: Base of skull fracture, Facial trauma (Obvious mid face injury)

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Advanced Airway Adjuncts 

Laryngeal Mask Airway (LMA)

    • Use: Acceptable alternative to mask anesthesia in operating room 
    • Indications:  
    • Short procedures when endotracheal intubation not necessary 
    • Rescue device after failed intubation 
    • Limitations:  
    • High airway resistance or poor lung compliance 
    • Uninterrupted chest compression likely causes leak 
    • Theoretical risk of gastric aspiration 

Endotracheal Intubation

    • Gold standard: Most technically difficult but most secure airway ,Only experienced providers should perform 

    • Indications:  
    • Unconscious patient with no significant respiratory efforts 
    • Partially/fully obstructed airway where basic airway ineffective 
    • Patients requiring invasive respiratory support for oxygenation/ventilatory failure 

    • Advantages:  
    • Protection from aspiration of blood/vomit 
    • Reliable adequate tidal volume with uninterrupted chest compressions 
    • Disadvantages: Technically difficult, requires trained personnel 

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Oxygen Therapy and Ventilation 

Basic Oxygen Support 

    • Indication: Room air saturation <94% 
    • Goal: Increase saturation >94% 
    • Avoid high flow oxygen when possible 

Mask Ventilation 

    • Position: Sniffing or ramped position with airway adjuncts 
    • Technique: Two-person preferred – “T-E” grip over “E-C” 
    • Volume: Just enough to raise c

Noninvasive Positive Pressure Ventilation (NIPPV) 

Indications 

  • Adequate ventilation but poor oxygenation 
  • Temporizing measure during other treatments 
  • Pre-oxygenation before intubation 
  • Alternative to invasive airway (DNR/DNI patients) 

Types 

  • CPAP: Same pressure (5-10 mmHg) during inspiration and expiration  
  • BPAP: Inspiratory pressure up to 15 mmHg, expiratory 5-10 mmHg 

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