MM/DD/2020

5:00-6:00 Airway Management

M Anesthesiology
LDT Janice Chan, M.D.



OUTLINE • Upper airway: consisting of the nasal and oral cavities, pharynx,
larynx, trachea, and principal bronchi
I.
Introduction X Air is warmed and humidified as it passes through the nares
II. Review of the Anatomy during normal breathing
III.
Airway Assessment X Resistance to airflow through the nasal passages is 2x that
IV. Airway Management Techniques through the mouth and accounts for almost 2/3 of total airway
V. Basic
Airway Adjunctis resistance
VI. Airway Equipment X Innervation of nasal cavity: Trigeminal Nerve (CN V)
VII. Transtracheal Techniques
VIII.
Insertion of the Tracheal Tube Nasal Cavity
IX. Airway Maneuvers

X.
Managing Difficult Airways in Infants and Children
XI. Tracheal Extubation (in Infants and Children)
XII. Airway Management in Infants and Children
XIII.
Sources

INTRODUCTION

Difficult Intubation/Laryngoscopy

• Competence in airway management is a critical skill
• for safely administering anesthesia
• Difficult tracheal intubation/laryngoscopy: defined as successful
intubation requiring more than three attempts or taking longer
than 10 minutes
• The incidence of difficult mask ventilation is defined as the • A diagram of the lateral wall of the nasal cavity illustrates its
inability to maintain oxygen saturation(>90%) or inability to sensory nerve supply. The anterior ethmoidal nerve, a branch of
prevent or reverse the signs of inadequate ventilation (0.07%- the ophthalmic division of the trigeminal nerve, supplies the
5%) anterior third of the septum and lateral wall (A). The maxillary
• Competence in airway management requires knowledge of the division of the trigeminal nerve via the sphenopalatine ganglion
anatomy and physiology of the airway supplies the posterior two thirds of the septum and the lateral
wall
REVIEW OF THE ANATOMY
Pharynx
Upper and Lower Airway

• Airway anatomy divided into upper and lower airway

• The nasal and oral cavities are connected to the larynx and
esophagus by the pharynx.
• The pharynx is a musculofascial tube that can be divided into the
nasopharynx, the oropharynx, and the hypopharynx.
• Nasopharynx is separated from the oropharynx by the soft
palate.
• The epiglottis demarcates the border between the oropharynx
and the hypopharynx.
• Innervation is by way of cranial nerves IX (glossopharyngeal)
and X (vagus)
• Airway resistance maybe increased by prominent lymphoid
tissue in the nasopharynx
• The tongue is the predominant cause of resistance in the
oropharynx


CPU College of Medicine | Magnus Animus Medicus | 2021
 X Function of pharynx: musculofascial tube connecting the • The most cephalad cartilage,
oral/nasal cavities to the esophagus and larynx the cricoid, is the only one
X Pharynx innervated by vagus and glossopharyngeal that has a full ring structure. It
is shaped like a signet ring,
Larynx wider in the cephalocaudal
dimension posteriorly
• Cricoid Pressure/Sellick’s
• The adult larynx is between the 3rd and the 6th cervical vertebrae Maneuver
• It functions in the modulation of sound and separates the trachea Cricoid pressure is
from the esophagus during swallowing. provided by an assistant
o This protective mechanism, when exaggerated, becomes, exerting downward
laryngospasm pressure with the thumb
• The larynx is composed of muscles, ligaments, and cartilages and index finger on the
(thyroid, cricoid, arytenoids, corniculates, and epiglottis) cricoid cartilage
• The vocal cords are formed by the thyroarytenoid ligaments and (approximately 5-kg
are the narrowest portion of the adult airway. pressure) so that the
o The anterior-posterior dimension of the vocal cords is cartilaginous cricothyroid ring is displaced posteriorly and
approximately 23 mm in males and 17 mm in females. the esophagus is thus compressed (occluded) against the
o The vocal cords are 6 to 9 mm in the transverse plane but underlying cervical vertebrae
can expand to 12 mm. This calculates to a glottic aperture of Conceptually, this maneuver should prevent spillage of
60 to 100 mm. An understanding of the motor and sensory gastric contents into the pharynx during the period from
innervation of the laryngeal structures is important for induction of anesthesia (unconsciousness) to successful
performing anesthesia of the upper airway placement of a cuffed endotracheal tube.
X Larynx/voice box for voice modulation Cricoid pressure probably should be applied before the
induction of anesthesia in selected patients. Although the
X Interventions to give during laryngospasm: muscle relaxants application of cricoid pressure is often performed,
and deepen anesthesia aspiration of gastric contents still has occurred during such
X While in bronchospasm: bronchodilators to dilate the application. The efficacy of cricoid pressure is not clear.
passages and corticosteroids Furthermore, downward external pressure on the cricoid
X Larynx innervation: Vagus Nerve cartilage may displace the esophagus laterally rather than
resulting in compression of the esophagus

AIRWAY ASSESSMENT

History and Anatomic Examination

• The goal of evaluating a patient’s airway:

o Identify any possible problem with maintaining, protecting,
and providing a patent airway during anesthesia
o Evaluation is performed with the aid of physical examination
and a review of the patient’s history and anesthetic records

X Divisions of Laryngeal Nerve

o Superior Laryngeal Nerve is further divided into two:
ü Internal laryngeal nerve (sensory): supplies
sensory fibers to the laryngeal mucosa
ü External laryngeal nerve (motor): innervates the
cricothyroid membrane
o Recurrent Laryngeal Nerve
ü All laryngeal muscles are innervated by the
Recurrent Laryngeal Nerve, except the cricothyroid
membrane
Trachea

• Begins at the sixth cervical vertebra and extends to the carina,
which overlies the fifth thoracic vertebra
• It is 10 to 15 cm long and supported by 16 to 20 horseshoe-
shaped cartilages

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 2 of 14

 Tight skin and TMJ involvement
Congenital syndromes associated with difficult intubation Scleroderma make mout opening difficult

Laryngoscopy may worsen Airway obstruction (lymphoid

Epiglottitis (Infectious) Sarcoidosis tissue)
obstruction
Abscess Obstructive swelling renders
(Submandibular, Distortion of the airway renders Angioedema ventilation and trcheal intubation
Retropharyngeal, facemask ventilation or tracheal difficult
Ludwig’s Angina) intubation extremely difficult
Endocrine or metabolic Large tongue, bony overgrowths
acromegaly
Croup, Bronchitis, Airway irritability with a tendency
for cough, laryngospasm, May have decreased mobility of
Pneumonia Diabetes mellitus the atlanto-occipital joint
bronchospasm
Large tonue and abnormal soft
Papillomatosis Airway obstruction tissue (myxedema) make
Hypothyroidism ventilation and tracheal intubation
difficult
Tetanus Trismus renders oral tracheal
intubation impossible Goiter may produce extrinsic
Thyromegaly airway compression or deviation
Traumatic foreign body Airway obstruction
Upper airway obstruction with loss
of consciousness
Neck manipulation may Obesity Tissue mass makes successful
Cervical spine injury
traumatize the spinal cord facemask ventilation difficult

Nasotracheal intubation attempts

Basillar skull fracture mat result in intracranial tube
placement

Airway obstruction, difficult

facemask ventilation and tracheal
Maxillary or Mandibular intubation
Injury
Cricothyroidotomy may be
necessary with combined injuries

Airway obstruction may worsen

during instrumentation
Laryngeal Fracture Endotracheal tube may misplaced
outside the larynx and worsen the
injury

Laryngeal Edema Irritable airway

(After intubation) Narrowed laryngeal inlet
Soft tissue Neck Injury
(Edema, Bleeding, Anatomic distortion of the upper
Subcutaneous airway
emphysema) Airway obstruction
Neoplastic upper airway
tumors (Pharynx, Larynx) Inspiratory obstruction with
spontaneous ventilation

Lower airway tumors Airway obstruction may not be

(trachea, bronchi, relieved by tracheal obstruction
mediastinum)
Lower airway is distorted

Fibrosis may distort the airway or
Radiation therapy make manipulation difficult
Mandibular hypoplasia, TMJ
arthritis, immobile cervical
Inflammatory vertebrae, laryngeal rotation, and 6-D Method of Airway Assessment
Rheumatoid Arthritis cricoarytenoid arthritis make
endotraceal intubation difficult • Six signs that can be associated with a difficult intubation:
Fusion of the cervical spine may 1. Disproportion
Ankylosing Spondylitis render direct laryngoscopy • Size of the tongue in relation to the oropharyngeal size
impossible
• A high Mallampati score (class 3 or 4) is associated with
Severe impairment of mouth more difficult intubation
TMJ syndrome opening • A higher incidence of sleep apnea

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 3 of 14

 • Mallampati Classification: maximal mouth opening and o Voice change
tongue protrusion in the sitting position (originally X Assess if there are masses
described without phonation) X Ask when the voice change started
o Subcutaneous emphysema
o Laryngeal immobility
o No palpable thyroid and/or cricoid
X Thyroid patients have difficult airway
o Neck asymmetry/tracheal deviation
3. Decreased thyromental distance
• Thyromental distance:
<7cm (<3 finger-
breadths: difficult
intubation)
• Underdeveloped
mandible
• Reflects an anterior
larynx and decreased
submandibular space
MALLAMPATI SCORING
4. Decreased inter-incisor gap
• Distance between the upper and lower incisor is < 4cm
or <2 finger breaths
• Causes of reduced
mouth opening
o Mandibular
condyle fracture
o Rigid cervical
collar
o TMJ dysfunction
o Trismus in tetanus
• Mallampati proposed a classification system (Mallampati infection
score) to correlate the oropharyngeal space with the
ease of direct laryngoscopy and tracheal intubation
• With the observer at eye level, the patient holds the 5. Decreased range of
head in a neutral position, opens the mouth maximally, motion in any or all joints of the airway
and protrudes the tongue without phonating • Atlanto-occipital joint, cervical spine and TMJ
• The airway is classified according to the visible • Sniffing position
structures: o Head extension <35 degrees
o Class I: The soft palate, fauces, uvula, and tonsillar o Neck flexion <35 degrees
pillars are visible o Short thick neck
o Class II: The soft palate, fauces, and uvula are o Cervical spine collar or C spine immobilization
visible X Patients with cervical fractures
o Class III: The soft palate and base of the uvula are X Correct intubation is aligning the 3 axes
visible o By 8-10 cm elevation under the occiput
o Class IV: The soft palate is not visible X 3 axes (POL)
• There is a correlation between the Mallampati score, o Pharyngeal
what can be seen on direct laryngoscopy, and the ease o Oral
of intubation o Laryngeal

Flexion of the neck align pharyngeal and laryngeal

axis; extend slightly, all three are aligned

• The laryngoscopic view is classified according to the

Cormack and Lehane score:
o Grade I: Most of the glottis is visible
o Grade II: Only the posterior portion of the glottis is
visible
o Grade III: The epiglottis, but no part of the glottis,
can be seen 6. Dental overbite
o Grade IV: No airway structures are visualized
• Large-angled teeth disrupt the alignment of the airway
2. Distortion axes and possibly result in decreased inter-incisor
opening
• Etiology: Neck mass, Neck hematoma, Neck abscess,
Previous surgery or trauma • Protruding maxillary incisors
• Predicting airway distortion problems

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 4 of 14

 Ventilation with a Facemask

• Failure to place an endotracheal tube is not the actual cause of
the severe adverse outcomes related to difficult airway
management; the primary problem is an inability to oxygenate,
ventilate, prevent aspiration, or a combination of these factors
• The mask is gently held on the patient's face with the left hand,
leaving the right hand free for other tasks. Air leak around the
edges of the mask is prevented by downward pressure
• The facemask should be held to the patient’s face with the
• The potential for airway difficulty is generally proportional to the fingers of the anesthesia provider’s left hand lifting the mandible
number of signs observed (chin lift, jaw thrust) to the facemask
• Pressure on the submandibular soft tissue should be avoided
Signs of Upper Airway Obstruction/Distress because it can cause airway obstruction
• The anesthesia provider’s left thumb and index finger apply
• Hoarse voice (recurrent laryngeal nerve problem) counter pressure on the facemask. Displacement of the
• Decreased air in and out mandible, atlanto-occipital joint extension, chin lift, and jaw thrust
combine to maximize the pharyngeal space
• Stridor
• Differential application of pressure with individual fingers can
• Retraction of suprasternal/supraclavicular/intercostal space improve the seal attained with the facemask. The anesthesia
• Cyanosis provider’s right hand is used to generate positive pressure by
compressing the reservoir bag of the anesthesia breathing circuit
Establishing a Patent Airway • Ventilating pressure should be less than 20 cm H2O to avoid
insufflation of the stomach
1. Non-equipment X Normal O2 sat:>95
• Head tilt/ chin lift/ jaw thrust X Most common cause of obstruction is the tongue so make
place the patient sideways to make the tongue fall away from
2. With Equipment the airway first if desaturating
• Oro/nasopharyngeal airway X If still desaturating after O2 cannula (2-4), oral airway
• Endotracheal intubation (mouthguard) for patent airway
X If still desaturating after oral airway, jaw-thrust maneuver for
• Laryngeal mask airway (LMA) patent airway and for no air leaks when putting face mask.
X If still desaturating after the maneuver, face mask; you can
AIRWAY MANAGEMENT TECHNIQUES increase your O2 from 6-10
X If still desaturating after face mask, Ambu bag
X After ambu bag if still desaturating. Intubate
X Fast decision and maneuver
X Very important is ventilation and not intubation

Assessment and Predictability of Difficult Mask Ventilation

• Inability of an anesthesiologist to maintain oxygen saturation
>92%
• Significant gas leak around face mask
• Need for greater than or equal to 4 liters per minute gas flow (use
of fresh gas flow button more than twice)
• No chest movement
• Two-handed mask ventilation needed
• Change of operator required

Independent risk factors for difficult mask ventilation

Before we intubate, there’s what we call 3 oxygenation: Odds ratio
1. Ask the patient to breathe deeply to expand FRC or O2
reserve
2. Give meds, let the patient sleep Presence of a beard 3.16
3. Intubate (prone to air leaks)

To intubate, open the mouth, then scissors maneuver, insert BMI > 26kg/m2
laryngoscope, BURP maneuver (backward upward rightward (difficult airway) 2.75
position), until you see glottic opening, insert it. If you feel the
resistance of the vocal cords, that’s when you stop. Lack of teeth
Pagsulod, kakas, pull-out the laryngoscope, inflate, kaptan, (edentulous; prone to air
takod sa anesthesia machine or ambu bag leaks) 2.28

*Put oral airways

How to confirm correct placement: Age > 55 years
1. Direct Visual Observation (seeing the glottic opening) (edentulous; prone to air
2. Chest rise leaks) 2.26
3. Stethoscope (5 auscultation points) *Put oral airways
4. Mist
5. O2 sat or NTidal CO2 capnograph

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 5 of 14

 Nasophrayngeal and Oral Airways
History of snoring
1.64
Obstructive Sleep Apnea

X Repeated attempts at laryngoscopy

X Mallampati class III to IV
X Neck radiation
X Male gender
X Limited ability to protrude the mandible
X Advancing age, obesity, multiple laryngoscopies, Mallampati
class III to IV, neck radiation, and snoring are indicators of
decreased compliance and increased resistance during
facemask ventilation
X An appropriately sized facemask and oral or nasal airways • Used for conscious patient who cannot maintain airway
may help mitigate these factors. A beard or lack of teeth may • Can be used with intact gag reflex
result in an inability to develop adequate positive pressure • Should not be used with head injuries or nosebleeds
with the anesthesia breathing circuit • The correct size airway is chosen by measuring the device on the
patient: the device should reach from the patient's nostril to the
Laryngeal mask airway: for patient with no risk of earlobe or the angle of the jaw
aspiration; 30 mins-1hr lang kay taga bag mo, gasulod ka • Can sometimes be useful in infants and pediatric px to relieve
sa baga, gasulod ka man sa tiyan airway obstruction esp. during facemask ventilation at beginning
and end of anesthesia
Most important: Positioning of patient (come out in exam) • Nasal airway must be:
Head of patient at OR table must be in line with xiphoid o Carefully placed through one of the nares after lubricating its
process; with pillow (10 cm elevation); >10cm, airway exterior
becomes closed o Long enough to pass through nasopharynx
o Short enough to remain above glottis
BASIC AIRWAY ADJUNCTS • Oral airways: relieve airway obstruction by displacing tongue
anteriorly
o Too large oral airway: obstruct glottis, may cause coughing,
• Oropharyngeal airways gagging, or laryngospasm in a px not deeply anesthetized
• Nasopharyngeal airways o Too small: push tongue posteriorly and make airway
• Endotracheal tubes obstruction worse
• Laryngeal mask airway
Laryngeal Mask Airways
• Combitube

Oropharyngeal Airways Laryngeal mask airways

are supraglottic airway
devices that can be
• Keep the tongue from blocking the airway used for both routine
• Allow for easier suctioning of the airway airway management as
• Used on unconscious patients without a gag reflex well as in difficult airway
situations. LMAs are
• Used in conjunction with bag valve mask ideally suited for
The correct size OPA is chosen by measuring from the middle situations in which the
of the persons mouth to the angle of the jaw patient is breathing
Oral airways relieve airway obstruction by displacing the spontaneously, but can
tongue anteriorly. Too large an oral airway will either obstruct also be used to deliver
the glottis or may cause coughing, gagging, or laryngospasm positive pressure
in a patient who Ventilation
is not deeply It consists of a 12-mm
anesthetized. ID flexible shaft
Too small an connected to a silicone rubber mask that seals with airway in
oral airway will the hypopharynx
push the tongue The distal tip of the cuff should be against the upper
posteriorly and esophageal sphincter (cricopharyngeus muscle), the lateral
make the airway edges rest in the piriform sinuses, and the proximal end seats
obstruction under the base of the tongue
worse. Oral An LMA does not protect the airway from aspiration and
airways should should not be routinely used in patients with full stomachs or
be placed with those at increased risk for aspiration. The LMA Classic is
care to prevent reusable and the LMA Unique is disposable
trauma to the The laryngeal mask is a device for supporting and
teeth and maintaining the airway without tracheal intubation. The
oropharynx laryngeal mask may be used as an aid to intubation
LMA size selection is determined by the patient’s weight

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 6 of 14

 Laryngeal Mask Airways CTrach

• A modified LMA Fastrach
• Has the same anatomically curved stainless steel tube and is
available in three mask sizes (3, 4, 5)
• Size selection, insertion (no cricoid pressure), and ventilation are
as with the LMA Fastrach
• Intended to be more rapid and less cumbersome technically than
the LMA Fastrach

• Requires a minimum inter-incisor distance of 3 cm

ProSeal LMA

• A modification of the
classic LMA
• The cuff of the
ProSeal LMA extends
onto the back of the
mask, which results
in an improved
airway seal without
Laryngeal Mask Airways Fastrach (Intubating LMA) increasing mucosal
pressure
• Designed to obviate the problems encountered when attempting o It has a second
to blindly intubate the trachea through a classic LMA lumen that
parallels the one
• Consists of an for the airway but
anatomically shaped opens at the
stainless steel tube distal tip of the
connected to a mask to act as an esophageal vent
laryngeal mask. It has
an attached handle to • When optimally seated, the ProSeal LMA effectively isolates the
aid insertion of the trachea from the esophagus, thus protecting the lungs from
device and to facilitate aspiration when a minimum of 10 mL of air has been placed in
optimization of its the LMA cuff
positioning to increase
the likelihood of I-Gel
successful blind
tracheal intubation • A supraglottic laryngeal mask airway available in sizes 1 to 5
through the device. A (including 1.5 and 2.5)
15-mm connector allows for ventilation of the patient’s lungs
• Has a soft noninflatable gel cuff, gastric vent tube, built-in
• The ILMA is designed to be used with a silicone Euromedical epiglottic rest, integral bite block, and a 15-mm connector
endotracheal tube (size 7.0 ID, 7.5 ID, or 8.0 ID)
o These tracheal tubes exit the laryngeal mask at a different • It can be used as a primary airway, or a conduit for intubation
angle than do standard endotracheal tubes and result in • It is of adequate diameter to pass a 6.0 ETT through a size 3, a
better alignment with the airway 7.0 ETT through a size 4, and an 8.0 ETT through a size 5
• Technique • Not recommended in patients who are at risk of aspiration, and
o With the patient breathing oxygen, the Chandy maneuver (lift should remain in situ for less than 4 hours
and posterior rotation) is used to optimize the position of the
ILMA before attempting tracheal intubation. A lubricated Air-Q
endotracheal tube is inserted into the ILMA
o It is recommended that the largest size that is appropriate for • Another laryngeal mask device that can be utilized either as a
the patient be used to minimize mucosal pressure from the primary airway or as an intermediary channel for intubation
cuff • Available in four sizes (1.5 to 4.5)
o The endotracheal tube should advance without resistance
toward the glottic opening and the trachea. If resistance is felt
beyond the point where the horizontal line passes into the Esophageal-Tracheal Combitube
ILMA, the cause depends on the depth that the tube has
advanced • A double lumen device that
ü Immediate resistance = ILMA too large can function as either an
ü Resistance 2cm distal to the horizontal line = secondary endotracheal device or an
to a down-folded epiglottis esophageal obturator
ü Resistance 3cm distal to the horizontal line = ILMA too • The 37-French small adult
small ETC can be used in patients
ü Resistance of 4-5 cm = too large an ILMA has been who are between 120 and 180
selected cm (4-6 ft) tall, and the 41-
French ETC is for patients
taller than 180 cm
o After verification of endotracheal intubation, the cuff of the
ILMA is deflated, the 15-mm endotracheal tube connector is • Technique
disconnected, and the ILMA is removed by using the o The ETC is passed blindly
stabilizer bar to push the endotracheal tube through the ILMA while lifting the patient’s
o 15-mm connector is reattached to the tube and the mandible with the other
anesthesia breathing circuit, and the patient’s lungs are hand. Alternatively, a
ventilated laryngoscope may be
used to aid insertion

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 7 of 14

 o ETC should be inserted without force, because this can result X Measure the correct number of ET
in esophageal tear or rupture o ETT size: may also be based on patient age and body
o The oropharyngeal cuff is inflated first with the prefilled weight
syringe attached to the blue pilot balloon X Adults Female 7
o The distal cuff is then inflated and ventilation begun through X Adults Male 8
the longer (blue) lumen, which ends in fenestrations between
the two cuffs 1. Uncuffed ETT
ü No breath sounds = ventilation should be attempted • For infants and smaller children because the appropriately
through the other lumen sized cuffed ETT would be smaller and would increase
ü Ventilation not detected = tube is probably placed to resistance and work of breathing
deeply in the esophagus and should pulled back and o Leak pressure must also be checked
ventilation attempted through the blue lumen again o If leak pressure is too high: ETT should be replaced with
• Clinical Uses a smaller ETT
o Positive-pressure ventilation o If too low: ETT should be replaced with a larger ETT
ü Recommendation: airway reflexes not be intact during
ETC use 2. Cuffed ETT
o Protects against aspiration • Minimizes need for repeated laryngoscopy and allows for
o Not intended for long-term airway management, should be lower fresh gas flows and decreased concentrations of
removed after a few hours to decrease the risk of ischemia of anesthetic gases detectable in operating rooms
tongue and subsequent edema formation o When used in infants and small children, inflation
pressure of cuff must be checked and monitored esp if
nitrous oxide is used
Laryngeal Tubes
3. Microcuff ETT
• A multiuse single-lumen silicone • Offer several distinct advantages compared to conventional
tube with a dual cuff system (a ETT
pharyngeal cuff and a blind o Cuff
distal esophageal cuff) ü Made from a microthin polyurethane membrane
• It is passed blindly into the ü Stronger than conventional ETT
pharynx ü Seals the airway at lower cuff pressures than
conventional
ü Shorter and placed closer to tip of endotracheal
tubeà increased chances of correct tube
placement
Pharyngeal Airway Xpress o Intubation Depth Mark
ü Indicates correct depth for insertion
• A disposable device ü Increases ability for correct placement
with a rigid curved tube
and a terminal end with
gills that seats at the Indications for Endotracheal Intubation
cricopharyngeus
muscle • Provide a patent airway
• It has a high volume, X Sleeping position, Put 10cm to pillow, then a little extension of
low-pressure the neck to align the oral-laryngeal
pharyngeal cuff and is • Prevent inhalation (aspiration) of gastric contents
inserted blindly • Need for frequent suctioning
• Facilitate positive-pressure ventilation of the lungs
Glottic Oropharyngeal Airway
• Operative position other than supine

• Operative site near or involving the upper airway
• A disposable single lumen tube that forms an airway seal with a
sponge-like distal tip • Airway maintenance by mask difficult

Cuffed Oropharyngeal Airway Technique for Endotracheal Intubation

• Consists of a modified conventional oral airway with a cuff at its
distal end
• When the cuff is inflated, it displaces the base of the patient’s
tongue anteriorly and passively elevates the epiglottis away from
the posterior pharyngeal wall

Endotracheal Tubes

• The appropriately sized endotracheal tube for infants and
children can be estimated by using the following formula:

(Age+16) / 4 = ET size

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 8 of 14

 • Flexion of the neck, by elevating the head approximately 10 cm, • Procedure: The tip of the straight blade is passed beneath the
aligns the laryngeal and pharyngeal axes. Extension of the head laryngeal surface of the epiglottis. Forward and upward
on the atlanto-occipital joint is important for aligning the oral and movement of the blade exerted along the axis of the
pharyngeal axes to obtain a line of vision during direct laryngoscope handle directly elevates the epiglottis to expose
laryngoscopy. These maneuvers place the head in the “sniffing” the glottic opening. Depression or lateral movement of the
position and bring the three axes into optimal alignment patient’s thyroid cartilage externally on the neck (known as
• Sniffing position: align the axes of the patient’s mouth, pharynx optimal external laryngeal manipulation [OELM] or backward
and larynx permitting direct visualization of the larynx by upward rightward pressure [BURP]) with the laryngoscopist’s
laryngoscopy right hand may facilitate exposure of the glottic opening
• Opening the patient’s mouth: Scissor maneuver - using the index Flex Tip (Heine, CLM) Blade
finger to pull the upper right incisor towards the operator serves
to open the mouth, extend the AO joint, and protect the lips and
teeth • This blade is similar to a Macintosh blade, but it has a hinged tip
X When you intubate careful with the teeth because it might that is controlled by a lever that is triggered with the thumb of the
enter the bronchus anesthesia provider’s left hand during direct laryngoscopy. The
X Make sure to assess if teeth is loose or if patient is having laryngoscope is inserted into the vallecula, and then the lever is
dentures deployed to increase the lift on the hyoepiglottic ligament
• Cricoid Pressure (Sellicks Maneuver) Choice of Laryngoscope Blade
o Applied by an assistant by exerting downward external
pressure with the thumb and index finger on the cricoid • The choice of laryngoscope blade is often based on personal
cartilage preference
o This displace the cartilaginous cricothyroid ring posteriorly
and compresses the underlying esophagus against the • Advantages cited for the curved blade include fewer traumas to
cervical vertebrae teeth with more room for passage of the endotracheal tube and
less bruising of the epiglottis because the tip of the blade does
not directly lift this structure
AIRWAY EQUIPMENT • The advantage cited for the straight blade is better exposure of
the glottic opening
• Laryngoscope blades are numbered according to their length
o A Macintosh 3 or 4 blade or a Miller 2 or 3 blade is the
standard intubating blade for adult patients
o Wis-Hipple is a 1 ½ straight laryngoscope blade which is
useful for children between 1 and 3 years old



Other Basic Airway Equipment



• Suction

• Oxygen Source

• Ambu Bag / Bag Valve Mask

• Oral / Nasal Airways

• Endotracheal Tubes / Stylets
• CO2 Detectors

• Laryngoscope Blades (Macintosh, Miller, Wisconsin)

• Supraglottic Devices
• LMA

Endotracheal Tube Stylets
Curved (Macintosh) Blade
• Using stylet stiffens ETT and makes it easier to manipulate during
• Larger flange that retracts the tongue to the left more effectively direct laryngoscopy
• May be useful in certain patients in which tongue is larger than • It is useful whenever a difficult tracheal intubation is anticipated
normal (eg. Beckwith-Wiedemann syndrome, trisomy 21)
• Procedure: The tip of the curved blade is advanced into the Types of Stylets
space between the base of the tongue and the pharyngeal • Gum Elastic Bougle
surface of the epiglottis. Forward and upward movement of the o Used successfully in patients with poor laryngoscopic view
blade exerted along the axis of the laryngoscope handle o Will typically stop at 24 to 40 cm when it enters the smaller
stretches the hyoepiglottic ligament, elevates the epiglottis, and bronchi
exposes the glottic opening
• Aka concave; the most common • Schroeder Stylet
• Macintosh 3 is most useful for children >11 years old o A disposable plastic articulating stylet that allows angle of the
endotracheal tube to be adjusted to the correct angle while
Straight (Miller) blade performing direct laryngoscopy and tracheal intubation

• Easier to use in infants and small children than curved blade • Frova Intubating Introducer
o Smaller profile: easier for smaller mouths o Has a distal angulated tip and an internal channel to
o Smaller tip: more effectively lifts the epiglottis than curved accommodate a stiffening stylet or allow jet ventilation
blade
o Miller 1 straight laryngoscope blade: most useful for infants • Lighted Stylets (Lightwand)
<1yr old o Useful adjunct for unexpected and expected difficult airway in
o Miller 2: between 3 and 10 yo infants and children
• Disadvantage: does not retract the tongue as well to the left side o Used in px with limited mouth opening or limited neck
of the mouth extension

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 9 of 14

 o Tracheal intubation with lighted stylet: simpler and quicker cords while allowing for either spontaneous or controlled
than intubation with fiberoptic bronchoscope ventilation and oxygenation and shielding bronchoscope from
o Used successfully in presence of secretions and bleeding secretions and bleeding
o Disadvantage: üSimplest to leave LMA or ILA in place until end of
üOperating room lights must be dimmed procedure while remembering to partially deflate the cuff
üSuccess rate is significantly lower when airway is deviated of LMA to prevent unnecessary pressure in oropharynx
from midline by mass or tumor
o Technique TRANSTRACHEAL TECHNIQUES
üPlaced through ETT so that tip of stylet is several mm
proximal to distal tip of ETT Cricothyrotomy
üLighted stylet with loaded ETT is manually angled to
between 90˚ and 120˚
üKey to successful use: stay midline and anterior • Can be performed in less than 30 seconds and has significant
üLight should remain bright red as it passes from advantages over transtracheal jet ventilation because it
supraglottic area into trachea establishes a definitive airway that can be used for up to 72
hours
üOnce lighted stylet is in trachea, ETT should be advanced
further into trachea and stylet removed • The larger diameter of a cricothyrotomy tube allows both
inhalation and exhalation to occur through the device, and it does
üLighted stylet can also be used for nasotracheal not rely on a patent native airway
intubation after appropriate vasoconstriction of nasal
mucosa to minimize bleeding
Transtracheal Jet Ventilation
• Seeing Optical Stylet
o A semimalleable stainless steel high resolution fiberoptic • The risk profile for transtracheal jet ventilation is similar to that for
endoscope cricothyrotomy and includes pneumothorax,
o Does not require head or neck movement or a large inter- pneumomediastinum, bleeding, infection, and subcutaneous
incisor gap emphysema
o As a result of the oxygen pressure used for transtracheal jet
Glidescope (Glidescope Video Laryngoscope or GVL) ventilation, these complications can become life threatening
very quickly

• Absolute contraindications to transtracheal jet ventilation are
• Also be useful for managing difficult airway in infants and upper airway obstruction or any disruption of the airway
children

• Consist of miniature fog-resistant high-resolution video camera
embedded in reusable laryngoscope blade INSERTION OF THE TRACHEAL TUBE
• Requires light source and image is viewed on a color monitor
• Major advantage:
o Ability to see “around a corner” and visualize larynx even with
limited neck extension or very anterior airways
o Facilitate teaching
o Easier to learn than fiberoptic bronchoscopy in that it mimics
skills of direct laryngoscopy
• Major Disadvantage
o Limited number of sizes
o Requires reasonable mouth opening to be used successfully

Fiberoptic Bronchoscope

• Flexible fiberoptic bronchoscope, another tool for difficult
pediatric airway

• Particularly valuable when mouth opening or neck mobility is
limited
• Disadvantages: • Trachea of infants and children is short: easy to accidentally
intubate main stem bronchus
o Limited field of vision
o Interference from bleeding, secretions • Appropriately position the infant/child with a roll under the neck
or shoulders
• Do not have suction channels
• Mouth should be viewed into 3 compartments:
• Have optics that are inferior to those of larger scopes o Tongue on the left
• Should be at least 1mm smaller in outside diameter than ID of o Laryngoscope blade in the midline
ETT o Endotracheal tube entering from the right corner of the mouth
• Technique • To bring the local cords into view: gentle, external posterior
o Infants and children, unlikely be able to cooperate if awake; pressure applied
easier to perform when asleep
• The endotracheal tube is held in the anesthesia provider’s right
o Some anesthesia providers prefer to maintain spontaneous hand at the level of thyroid or cricoid cartilage like a pencil and
ventilation during fiberoptic bronchoscopy and tracheal introduced into the right side of the patient’s mouth with the
intubation esp if there is concern about ability to ventilate natural curve directed anteriorly
patient with facemask
o Easier to administer neuromuscular blocking drugs to • It should be advanced toward the glottis from the right side of the
pediatric px to provide better viewing conditions with less mouth as midline insertion usually obscures visualization of the
movement, less fogging of bronchoscope, less chance of glottic opening
laryngospasm • The tube is advanced until the proximal end of the cuff is 1 to 2
o Nasal fiberoptic laryngoscopy and tracheal intubation: cm past the vocal cords, which should place the distal end of the
vasoconstrictor (phenylephrine) should be administered to tube midway between the vocal cords and carina
prevent bleeding which will make visualization difficult • Correct tracheal depth of a cuffed endotracheal tube: estimated
o Oral fiberoptic laryngoscopy and tracheal intubation: LMA or by placing double line at the distal end of endotracheal tube at
ILA can provide an excellent channel directly to the vocal the vocal cords while performing direct laryngoscopy

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 10 of 14

 • Correct tracheal depth of uncuffed endotracheal tube: estimated o Lip, tongue, mucosal laceration
by palpating the ETT in the suprasternal notch o Dislocated mandible
• At this point, the laryngoscope blade is removed from the o Retropharyngeal dissection
patient’s mouth. The cuff of the endotracheal tube is inflated with o Cervical spine
air to create a seal against the tracheal mucosa. This seal • Airway Trauma
facilitates positive-pressure ventilation of the lungs and o Mucosal inflammation
decreases the likelihood of aspiration of pharyngeal or gastric o Excoriation of nose
contents • Tube Malfunction
• Use of the minimum volume of air in a low-pressure high-volume o Obstruction/kinking
cuff that prevents leaks during positive ventilation pressure (20 to • Aspiration
30 cm H2O) minimizes the likelihood of mucosal ischemia
resulting from prolonged pressure on the tracheal wall.
Nevertheless, all aspects of tracheal intubation can produce AIRWAY MANEUVERS
some type of laryngotracheal damage
• For example, ciliary denudation has been found to occur • Head Tilt, Chin Lift
predominantly over the tracheal rings and underlying the cuff site
after only 2 hours of intubation and with tracheal wall pressure
below 25 mm Hg
• Other serious complications attributable to endotracheal cuff
pressures include:
o Tracheal Stenosis
o Tracheal Rupture
o Tracheoesophageal Tracheocarotid Fistula
o Tracheoinnominate Artery Fistula
• Correct positioning of endotracheal tube is confirmed by:
o Capnography • Jaw Thrust
o Watching chest rise and fall
o Auscultation
• After confirmation of correct placement (end-tidal CO2,
auscultation for bilateral breath sounds, ballottement of cuff in the
suprasternal notch), the endotracheal tube is secured in position
• Reconfirming correct positioning of ETT: listening for equal
bilateral breath sounds after securing the ETT and later when
there is a change in patient’s position


• Possibility for ETT to shift into main stem bronchus during
laparoscopic case: when insufflation of abdomen causes a
cephalad shift of diaphragm and lungs
• Neuromuscular blocking drugs: make it easier to perform
direct laryngoscopy and intubation and will decrease

incidence of laryngospasm
Atlanto-Occipital Extension or Neck Mobility
• Nonemergency situations: nondepolarizing neuromuscular
blocking drugs (e.g. rocuronium) are used


Confirmation of correct ET placement

• Immediate Absolute Proof

o Observing tube passing through vocal cords
o Observing carbon dioxide (ETCO2)
o Visualizing tracheal lumen using fiberoptic scope
• Indirect Confirmation
o Listening over epigastrium = absence of breath sounds with
ventilation
o Observing chest to rise and fall with PPV
o Listening to apex of each lung for breath sounds with
ventilation
X Glottis opening is beside esophagus Flexion of the neck, by elevating the head approximately 10
X Esophageal intubation: after inserting, pump the bag, cm, aligns the laryngeal and pharyngeal axes.
when stomach inflates, pull out immediately (wrong Extension of the head on the atlanto-occipital joint is important
placement) à ventilate to raise O2 sat via face mask. If 99 for aligning the oral and pharyngeal axes to obtain a line of
– 100% O2 sat, try again. vision during direct laryngoscopy
X What to expect: chest should rise, equal breath sounds, These maneuvers place the head in the “sniffing” position
mist in the ET tubings and bring the three axes into optimal alignment.
X If unequal chest expansion, pull out by 1 cm until equal Atlanto-occipital extension is quantified by the angle
traversed by the occlusal surface of the maxillary teeth when
Complications the head is fully extended from the neutral position.
More than 30% limitation of atlanto-occipital joint extension
from a norm of 35 degrees, or less than 80 degrees of
• Malposition extension/flexion, is associated with an increased incidence
o Esophageal/bronchial intubation of difficult tracheal intubation
• Trauma
o Tooth damage

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 11 of 14

 Addendums
Expected Difficult Airway

• Should be approached with caution
• Only preanesthetic medications that have minimal ventilator
depressant effects (eg.midazolam) should be used
• Preanesthetic medications should be administered where there is
appropriate airway equipment
• Pulse oximetry monitoring: initiated at this time
• Additional anesthesia colleague should be available for help
during:
o Induction of anesthesia
o Inserting IV line
o Securing airway
• Most difficult decision in managing an expected difficult pediatric
airway: whether to attempt direct laryngoscopy or to proceed
directly with an alternative strategy
• History and PE may indicate situations in which direct
laryngoscopy will be unsuccessful
• Cases that need to directly proceed to alternative strategy:
o Halo traction preventing neck extension
• Techniques of Common Airway Indexes Measurement o Limited mouth opening
o Thyromental Distance: measured along a straight line from tip • LMA Ctrach and LMA Fastrach: usable only for children >30kg
of mentum to thyroid notch in neck-extended position. • McGrath Video Laryngoscope: very useful in difficult situations
o Mouth Opening: interincisor distance (or interalveolus but no available pediatric sizes (only for larger children)
distance when edentulous) with the mouth fully opened.
o Mallampati Score TRACHEAL EXTUBATION (IN INFANTS AND CHILDREN)
o Head and Neck Movement: the range of motion from full
extension to full flexion • The patient must be either deeply anesthetized or fully awake at
o Ability to prognath: Capacity to bring the lower incisors in the time of tracheal extubation
front of the upper incisors
• Tracheal extubation during a light level of anesthesia
(disconjugate gaze, breathholding or coughing, and not
MANAGING DIFFICULT AIRWAYS IN INFANTS AND CHILDREN responsive to command) increases the risk for laryngospasm
• Patient reaching for the endotracheal tube might indicate a
• Same general principles for managing normal pediatric airway localizing response to noxious stimulation in the absence of
apply to either managing unexpected or expected difficult sufficient awakening from anesthesia to follow commands
pediatric airway • Tracheal extubation before the return of protective airway
reflexes (deep tracheal extubation) is generally associated with
Unexpected Difficult Airway less coughing and attenuated hemodynamic effects on
emergence
• Most important first step: call for an additional anesthesia • Contraindications:
colleague to help o Previous difficult facemask ventilation or ET
• Repeated attempts at direct laryngoscopy: can result in trauma o Risk for aspiration
to the upper airway, edema, bleeding o Surgical procedures resulting in airway edema or increased
airway irritability
• LMA: may be the only way to maintain an airway until patient
wakes up or surgical airway is established • Techniques
o Spontaneous breathing with 100% oxygen is established
before tracheal extubation
üAn FRC filled with oxygen allows for the longest safe
period should breath-holding or laryngospasm occur
immediately after tracheal extubation
o Oropharynx is suctioned just before tracheal extubation
o The endotracheal tube cuff is deflated and the tracheal tube
rapidly removed from the patient’s trachea and upper airway
while a positive-pressure breath is delivered to help expel any
secretions
üCuff should not remain deflated for any significant period
before tracheal extubation because the vocal cords canot
effectively close around the ET and supraglottic
secretions can be aspirated
o Timing tracheal extubation at the peak of inspiration is
intended for the following exhalation or cough to eliminate any
aspirated secretions from the trachea
o After tracheal extubation, oxygen is delivered by facemask

Croup or Stridor

• Infants and children, more likely at risk than adults
• Croup: occurs most commonly when either cuffed or uncuffed
ETT is used that is too large or when inflated with too much air

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 12 of 14

 • Resulting mechanical pressure on tracheal mucosa: venous
congestion and edemaà narrow tracheal lumen; severe cases, o How to minimize likelihood of dental trauma:
arterial blood supply compromise and mucosal ischemia üUse of a plastic shield placed over the upper teeth
• Other risk factors for croup: üAvoidance of using the laryngoscope blade as a lever on
o Multiple tracheal intubation attempts the teeth
o Unusual positioning of head during surgery o Systemic hypertension and tachycardia
o Increased duration of surgery üFrequently accompany direct laryngoscopy (regardless of
o Procedures involving upper airway (eg. Rigid bronchoscopy) the type of laryngoscope blade used) and tracheal
intubation
• Manifestations
o Respiratory distress in postanesthesia care unit üUsually transient and innocuous
o Nasal flaring, retractions, increased respiratory rate, audible üIn patients with preexisting systemic hypertension or
stridor, decreased oxygen saturation ischemic heart disease: duration of direct laryngoscopy
should be as short as possible
• Treatment o Serious or persistent cardiac dysrhythmias during tracheal
o Mild symptoms intubation: unlikely if apneic time is minimized and adequate
üHumidified oxygen oxygenation and denitrogenation are performed
üProlonged observation in postanesthesia care unit o Direct upper airway trauma are more likely to occur with
o More severe cases difficult tracheal intubation because of the
üAerosolized racemic epinephrine üApplication of more physical force to the patient’s airway
üPostoperative observation in ICU than is normally applied
o Patients with respiratory distress not relieved by measures üThere’s need for multiple attempts at intubation
mentioned: Reintubated w/ ETT smaller than previously used o Most common consequence: chipped or broken tooth
o IV steroids for preventing upper airway edema: more
beneficial when given before airway is instrumented and • Complications while the Tracheal Tube is in Place
should be instrumented before rigid bronchoscopy o Obstruction of the tracheal tube may occur as a result of
inspissated secretions or kinking
Obstructive Sleep Apnea o Chance of endobronchial intubation can be minimized by:
üCalculating the proper endotracheal tube length for the
• Infants and children with OSA: significant risk for airway patient
obstruction, respiratory distress, potential for apnea üNoting the centimeter marking on the tube at the point of
postoperatively fixation at the patient’s lips
• Residual inhaled anesthetics orresidual neuromuscular o Adults
blockades: can depress airway reflexes, skeletal muscle tone üDistal end of ETT in midtrachea: taping the ETT at the
and strength, and respiratory driveà airway compromise patient’s lips corresponding to the 21- to 23-cm markings
on the tracheal tube
• Opioids: must be very carefully titrated intra and postoperatively o Flexion of head may advance the tube up to 1.9 cm and
because they can depress ventilator drive and contribute to convert a tracheal placement into an endobronchial
significant hypercapnia and arterial hypoxemia intubation, esp in children
• Tracheal extubation in patients w/ OSA: considered only when px o Extension of the head can withdraw the tube up to 1.9 cm
are fully awake and result in pharyngeal placement
• All infants and children with OSA must be monitored o Lateral rotation of the head moves the distal end of the
postoperatively w/ pulse oximetry and apnea monitoring tracheal tube approximately 0.7 cm
• High-risk patients: postoperative monitoring in ICU setting
• Immediate and Delayed Complications after Tracheal Extubation
Extubation After a Difficult Intubation o Two most serious potential immediate complications after
tracheal extubation:
• Considered carefully because reintubation can be more difficult üLaryngospasm
than the initial intubation • Unlikely if depth of anesthesia is sufficient or when
(suppressed laryngeal reflexes)
• Tracheas of infants and children with difficult airways should only
be extubated when: • Patient is allowed to awaken before tracheal
o Fully awake extubation (intact laryngeal reflexes)
o No residual neuromuscular blockade üInhalation of gastric contents
• Postoperative factors that can compromise respiratory function: o Patient lightly anesthetized at the time of tracheal extubation:
o Postoperative pain esp if there is splinting from abdominal or at most risk (laryngeal reflexes neither adequately
thoracic incision suppressed nor recovered)
o Postoperative pain requiring significant opioid use: decrease o If laryngospasm occurs:
respiratory drive üOxygen delivered with positive pressure through a
o Regional anesthesia (eg. Epidural): hasten ability to extubate facemask and forward displacement of the mandible
trachea üAdministration of succinylcholine (0.1 mg/kg IV) or an
o Edema of airways from surgical trauma, positioning or anesthetic induction
excessive fluid administration o Pharyngitis: most frequent complaint after tracheal extubation
• Infants and children with postoperative airway edema: must üParticularly in females: thinner mucosal covering over the
remain intubated until edema has resolved posterior vocal cords than in males
üUsually disappears spontaneously without any treatment
in 48 to 72 hours
Complications of Tracheal Exubation o Damage to tracheal mucosa: major complication of
prolonged tracheal intubation (>48 hours)
• Complications During Direct Laryngoscopy And Tracheal o Stenosis: symptomatic when the adult tracheal lumen is
Intubation decreased to less than 5 mm
o Dental trauma: most frequent type of damage related to direct
laryngoscopy
o ~1 in every 4500 patients
o Patients at likely risk for dental injury
üThose with preexisting poor dentition
üThose who possess upper airway anatomy

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 13 of 14

 AIRWAY MANAGEMENT IN INFANTS AND CHILDREN • Hypoplastic mandible
• Difficult airway management expected if the infant’s chin is
Airway Differences between Infants and Adults posterior to the upper lip
• Normal Airway: if the chin is neutral to the upper lip
• Usually by the time the child is about 10 years old, the upper • Loose teeth: avoid trauma or aspiration
airway has taken on more adult-like characteristics
Preanesthetic Medication
Infants Adults • Often not necessary in infants younger than 6 months because
Larynx C3-C4 level C4-C5 stranger anxiety does not usually develop until 6 to 9 months of
(causes the tongue to age
shift more superiorly • Midazolam: oral, IV, intranasal, IM, rectal
closer to the palate and
may cause airway
obstruction in situation Induction of Anesthesia
such as inhalation • If patient has an intravenous catheter, induction of anesthesia
induction of with propofol or thiopental is usually safer and quicker
anesthesia)
• Propofol: more quickly metabolized and eliminated than
Tongue Larger in proportion to thiopental; IV administration is painful
the size of the mouth • Thiopental: relatively low cost and lack of pain on IV
(makes direct laryngoscopy administration
more difficult; contribute to
obstruction of the upper • LMA can be inserted or a neuromuscular blocking drug can be
airway during sedation, given to facilitate direct laryngoscopy and tracheal intubation
inhalation induction of • Inhaled induction of anesthesia can be performed if the infant or
anesthesia, or emergence child does not have an intravenous catheter in place
from anesthesia // resolution:
anterior pressure on the • The increasing level of anesthesiaàdecrease skeletal muscle
angle of the mandible to shift toneàmay cause airway obstruction
the tongue to a more
anterior position or an oral or • If airway obstruction does occur, it can usually be relieved by:
nasal airway can also be o Opening the mouth
beneficial in these situations) o Extending the neck
o Pushing anteriorly on the angle of the jaw
Epiglottis Relatively larger, stiffer, o Occasionally, an oral or nasal airway may need to be inserted
and more omega- at this point
shaped
Angled in more
posterior position SOURCES
(blocking visualization of the
vocal cords during direct
laryngoscopy) • Powerpoint Presentation
• Miller 6th Ed.
Airway Funnel-shaped with Vocal cords • MCC Trans
relatively large thyroid (narrowest portion in an
• Recordings
cartilage above and a adult’s airway)
relatively narrow cricoid
cartilage below
(narrowest portion of an
infant’s airway)

Proper Shoulder or neck roll Sniffing position
position for
Direct
Laryngoscopy
Nares Relatively small

Managing the Normal Airway in Infants and Children

HISTORY
• Any problems with previous anesthetics, and previous anesthetic
records
• History of snoring
PHYSICAL EXAMINATION
• Asking a child to look up at the sky and then down at the floor is
one way of assessing neck extension and flexion, respectively
• Any masses, tumors, or abscesses in the neck or upper airway
that compromise neck flexion, extension, or breathing function,
further evaluation is important
o Computed tomography to evaluate the location and degree of
any airway compromise
• Children will often voluntarily open their mouths: determine
Mallampati classification
• Uncooperative child/infant: external examination of the airway
often reveals enough information to determine whether it is a
normal or a potentially difficult airway
• Thyromental distance is (eg short)
• Micrognathia

CPU College of Medicine | Magnus Animus Medicus | 2021 Page 14 of 14