Airway Management in

the Neurological and

Neurosurgical Patient

dr Syah Reza Manefo

Departement of Neurosurgery
Faculty of Medicine Universitas Padjadjaran
Hasan Sadikin General Hospital
Bandung 2022
●
Introduction
This anatomical and functional distribution of the oropharynx, nasopharynx, and larynx allow for
communication, mastication, swallowing, and continuous respiration.

● Airway difficulties  50–70% of head injuries experiencing associated facial injury. Airway compromise can
arise from associated soft tissue swelling (often with frightening speed of onset), hemorrhage and secretions,
and fractured teeth.

● Maxillary fractures Facial edema and pharyngeal blood, but may also disrupt the skeletal support of the
oropharyngeal musculature  Obstruction.

● Focal neurological insults to the midbrain, cerebellum, or brain stem (injury, stroke, demyelination) can
adversely affect airway control centers. More diffuse disease (injury, infection, inflammation, ischemia) can
threaten consciousness with the consequent impairment of cough and swallow. A decreased level of
consciousness can lead to a reduction in airway muscle tone  airway obstruction  Hypoxia, Hypercarbia,
and further Diminishes airway control.
 Assesment
The urgency of intubation consider the neurological condition of the patient and the
potential effects of hypercarbia and/or hypoxia. Either will lead to cerebral
vasodilation with subsequent increases in cerebral blood volume and intracranial
pressure. The need for intubation requires clinical judgment. Once the decision has
been made to intubate the patient, a number of questions will need to be addressed. .

● What precautions are required?

● How easy is it to maintain a patent airway?

● How easy is it to intubate the airway?

Indication
 Preparation
(Tools)
• This requires a thorough preprocedural preparation that should include optimization of
the environment, with suction equipment connected, tested, and immediately at hand.
1. Oxygen
2. Tubing (A 7 mm tube (adults and induce minimal flow restrictions. Larger tubes (8
mm), however, do allow for easier suctioning and/or bronchoscopy if needed) and an
inflatable bag are essential.
3. Removing the gastric content prior to intubation is desirable since most patients will
not have been fasting in an emergency situation. Existing gastric tubes should be
drained, but insertion at this point is not recommended.
4. Monitor vital signs and oxygenation, to immobilize the head in case of cervical
spine injury (see below), or to apply cricoid pressure. This maneuver presses on the
only competent cartilage ring in the trachea to compress and close the esophagus. If
cricoid pressure is to be utilized, the clinician should carefully inform the assistants
 Preparation
(Induction Drugs)
• Hypnotics,
1. Thiopental (3–5 mg/kg) and propofol (2–3 mg/kg)  Reduction in cardiac output.
2. Etomidate (0.3 mg/kg) has the least hemodynamic effect
3. Ketamine (1–2 mg/kg)  increase blood pressure with attendant tachycardia.
4. Midazolam (0.3–0.4 mg/ kg) slight hypotension but less than propofol or thiopental. All agents
will produce transient apnea but ketamine has the least effect, followed by etomidate.
5. Fentanyl (1–2 mg/kg) can synergistically reduce hypnotic doses at induction and serves to
decrease subsequent coughing, as well as respiration. the most useful at induction.

• Paralytic drugs highest quality relaxation for intubation,

1. Succinyl choline (1–1.5 mg/kg) The shortest duration of effect is 3–5 minutes. Fastest overall
onset (45 s) limitations hyperkalemia seen in burns and the recently immobilized (more than
72 hours since burn/ immobility).
2. Vecuronium, Rocuronium or Cistracurium are acceptable alternatives, with rocuronium (1
mg/kg) swiftly working at 60 seconds post injection, but the effect lasting longest to 60 minutes.
Cisatracurium (0.15 mg/kg) and vecuronium (0.1 mg/kg) take 2–3 minutes respectively to work,
but effects last for 30–40 minutes.
 Preparation
(Supporting The Airways)

• In the supine position, there is a tendency

for both the mandible and tongue to fall
back against the posterior pharyngeal
wall obstructing the airway. The
application of jaw lift is achieved by
applying upward pressure at the angle
of the mandible, without moving the
neck (crucial in circumstances of
trauma without cervical spine
clearance), or pushing the tongue into
the pharynx. The insertion of an
oropharyngeal airway will help to
position the tongue anteriorly,
particularly in the edentulous. An
inexperienced provider can support the
jaw with the fourth and fifth fingers of
each hand, sealing the mask to the face
with the thumb and first finger, while an
assistant squeezes the bag.
 Preparation
(Difficult Mask Ventilation)

• Difficult mask ventilation (3-8% cases) (DMV)  Unable to keep the arterial pulse oximetry
saturations above 92%, or to avoid and correct for signs of inadequate ventilation during positive-
pressure mask ventilation.
• A useful mnemonic to identify a possible DMV patient is O-B-E-S-E, where:
1. O = Obese patient (BMI > 26),
2. B = Bearded patient,
3. E = Elderly patient (age > 55),
4. S= Snoring history of patient,
5. E =Edentulous patient.

• Alternatively, should be kept by the bedside  anticipated laterNasal airways can be used with
caution, having a higher frequency of bleeding on insertion (Contraindicated in facial injuries or
basal skull fractures) In circumstances of difficulty in bag/mask ventilation, there are now a large
variety of supraglottal airways, which all offer the ability to bring the airway closer to the
epiglottis, and stay securely seated in the pharynx. They do not protect the lungs from aspiration,
and indeed may obscure the presence of vomitus in the pharynx.
 Preparation
(Difficult Airway Intubation)
• Difficult intubation has a similar
prevalence (1–8%)  A need for more
than three attempts at intubation or
attempts that last longer than 10 minutes.
Difficult intubation is usually associated with
limited exposure of the glottis on direct
laryngoscopy. The best known is the
Mallampati score introduced in 1985. This
requires patient cooperation, which limits its
utility in the ICU, but may be available from
a previous assessment. Classification from
grade I to IV is associated with an increasing
difficulty of intubation (and also of mask
ventilation). Shows the scores obtained on
examining the soft tissues of the pharynx in a
seated patient with his mouth open and silent
extension of the tongue. Specificity and
sensitivity for this scale range widely in the
literature, from 40 to 60% and 70 to 95%
respectively.
 Preparation
(Difficult Airway Intubation)
• The LEMON score summates a variety
of anthropometric features along with
somatypic characteristics and neck
mobility. It uses four “look” criteria,
three “evaluate” criteria, the presence of
airway obstruction,
 Preparation
(Difficult Airway Intubation)
• The adequacy of any view itself should be recorded for future information. This can be expressed on the Cormack–Lehane scale –
from 1 to 4 depending on the decreasing visualization of vocal cords past epiglottis or tongue (Figure 2.2). There are a number of
accessory devices that should be considered for inclusion in a “difficult airway kit” and it is the practice in many institutions to have
one of these available in each unit or floor.

1. The simple bougie is a straight cathetether. Eschmann bougie allows placement through the glottis under direct vision, and an
endotracheal tube can then be passed over the bougie. The Cook exchange catheter serves the same purpose but allows for a modest
flow of oxygen. This flow is insufficient to allow ventilation but can maintain oxygenation in some circumstances. A malleable
stylet inside the endotracheal tube can be molded to curve toward a larynx aligned anteriorly to the axis of view.
2. Articulated laryngoscope blades (McCoy) with the ability to exert more lift at the epiglottis, to video assisted laryngoscopes. The
intubating laryngeal mask (ILMA) is a specially adapted supraglottic airway. When positioned above the glottis, an accompanying
endotracheal tube can be inserted through the ILMA into the trachea. The ILMA can then be removed or remain in place. Fiberoptic
intubation is commonplace in the operating room and can transform an “impossible” intubation into a practical procedure.
3. Fiberoptic procedures require an anesthetized airway, by either local or general anesthesia,  provoke secretions, bleeding,
laryngospasm, coughing, and hypoxia. In these circumstances a“macroscopic” viewofdirect laryngoscopy is probably superior. Once
the endotracheal tube has been placed through the glottis, markers on some makes of tube signify an appropriate depth of insertion
when positioned at the level of the vocal cords.
4. The gold standard for tracheal placement is CO2 detection. Portable devices are available that reflect either color change or display
measured CO2 concentrations as a waveform and/or numerical value. Relying on chest movement and breath sounds are inadequate
and have fooled many experienced providers.
 Preparation
(Difficult Airway Intubation)
 (Difficult Airway Intubation, When To Stop )

• Be carefull for Hypoventilation and Hypoxia in the patient, in their desire to place an
endotracheal tube. After three unsuccessful attempts to intubate, the ASA task force recommends
proceeding through their difficult airway algorithm (irrespective of the experience of the provider).
A failure of intubation does not necessarily mean a failure to ventilate.
1. Changes in the patient’s position may improve the intubating conditions;
2. The insertion of a supraglottic airway is appropriate; or
3. a cricothyroidotomy is required.
• A 14 g intravenous cannula can be placed through the
cricothyroid membrane into the trachea, the needle
withdrawn and the catheter connected to the empty barrel
of a 5 mL syringe with the plunger removed.
• This syringe barrel will serendipitously connect to a 7 mm
or 7.5 mm ET tube connector. This allows connection to a
standard oxygen source for small-volume ventilation.
 Preparation
(Difficult Airway Intubation)
 Suspected Cervical Spine Injury and Intubation

• Trauma patients should always be considered to have a cervical spine injury until
otherwise cleared.
• Immobilization of the neck during intubation by an assistant in either of two positions:
1. stabilizing the head from “above” by crouching to the side of the intubator and
supporting the head between outstretched hands with the fingers stabilized on the
patient’s shoulders;
2. Stabilizing from “below” with the fingers on the mastoid processes and the thumbs on
the zygomas with wrist and forearms bracing the patient’s neck on the shoulders.

• Once the neck is supported, the front of the collar is removed to allow mandibular
movement. There should be no flexion or extension of the neck iatrogenic spinal cord
damage. The back of the collar may be left on. The head is left in a neutral position for
laryngoscopy. Once the ET tube is placed, the collar is reassembled
Suspected Cervical Spine Injury and Intubation
EXTUBATIO
N

The possibility of swelling should be

considered along with an assessment
of the ability of cough and gag
reflexes to protect the airway. This
must be performed in the context of
the overall neurological state of the
patient. Swelling of the airway and
cords is a noted problem that leads to
secondary reintubation
THANK
YOU