Airway Anatomy
Soft palate
Hard palate
Nasopharynx
Tongue
Oropharynx
Hypopharynx
Thyroid cartilage
Airway Anatomy
Hyoid bone
Thyroid cartilage
Cricoid cartilage
Trachea
Cricothyroid membrane
Airway Anatomy
Vallecula
Epiglottis
True vocal cords
False vocal cords
Cuneiform cartilage
(arytenoids)
Pyriform sinus
Corniculate cartilage (arytenoids)
Airway Anatomy
Trachea
Carina
Bronchi
Airway management tools
 Chin lift / jaw thrust
(most basic)
 BVM
 Airway adjuncts: oral, nasal
 Non-visualized advanced airways (supraglottic)
 Laryngeal Mask Airway (LMA)
 Laryngeal Tube (ie. King LT)
 E-T Combitube (dual lumen)
 Endotracheal intubation (by various means)
 Cricothyrotomy
(most advanced)
CONTINUUM IN WHICH ALL ARE IMPORTANT
Airway management
Visualization axis
Prehospital decision to intubate
Maintaining airway?
no
Airway manuevers, Adjuncts
Now maintained?
yes
Intubate
yes
no
Coma cocktail successful?
Protecting airway?
yes
no
yes
Ventilating / oxygenating
adequately?
yes
no
no
Coma cocktail,
supp. O2 successful?
BVM, intubate
no
yes
Deterioration / airway
compromise likely?
yes
no
Supp. O2, Observe, Transport
Consider intubation vs. close observation
Rapid transport
Difficult airways
 “The difficult airway is something one anticipates; the
failed airway is something one experiences.”
- Ron Walls
Difficult BVM - MOANS
 Mask Seal

Facial hair, deformity, blood
 Obesity / Obstruction

Cancer, lesions, excess tissue
 Age

>55, higher risk of poor BMV
 No teeth

Teeth keep face from caving in during BMV
 Stiff / Snoring

Lung resistance issues (edema, COPD)
Difficult Intubation - LEMON
 Look externally
 Evaluate 3-3-2 ideal
 3 fingers in open mouth (mouth opening size)
 3 fingers chin to hyoid (size of tongue in relation to pharynx)
 2 fingers hyoid to thyroid cartilage (larynx in relation to
tongue base)
 Mallampati score
LEMON - Mallampati
Best
Worst
LEMON
 Obstruction
 Known issues (hematomas, cancers, etc)
 Muffled voice, stridor, or difficulty swallowing
 Neck mobility
 Inability to line up axis will make more difficult
Failed airway
 Definition: 1. unable to intubate by multiple attempts

2. failure to intubate and oxygenation
cannot be maintained
or:
 Need to decide which situation is in place:
 Can’t intubate, can ventilate – go with the basics
 Can’t intubate, can’t ventilate – go with the
cricothyrotomy
Review of intubation
 Setup for intubation (already being ventilated with BVM)
 Stylet
 Endotracheal tubes (multiple sizes)

Average male: 8.5 mm average female: 7.5 mm (8.0 and 7.0
commonly used in EMS)
 Laryngoscope and blades (curved and straight, multiple





sizes) - check light
Syringe for inflation of balloon
Suction
Alternate airway devices
Verification method (colorimetric, capnograph, stethoscope)
Securing device
Steps of intubation
1. Laryngoscope in left hand, loose grip with fingers
2. Position the airway (initially sniffing position if
3.
4.
5.
6.
7.
possible)
Open the mouth with right hand
Insert blade on far right side
Swing to the midline, moving tongue to the left
Upward pressure in the direction of the handle to
expose the vocal cords (no levering)
Keep visual contact with vocal cords while obtaining
ET tube
Steps of intubation
8. Insert tube from right corner of mouth (bevel
9.
10.
11.
12.
13.
14.
horizontal)
Rotate 90 degrees (bevel vertical) and insert through
the vocal cords at midline until balloon passes
completely through
Remove laryngoscope
Remove stylet (hold your tube!)
Inflate balloon with 7 – 10 mL of air
Ventilate and verify the tube by multiple means
Secure the tube
Intubations
http://www.youtube.com/watch?v=mvWUcP7LFMo
http://www.youtube.com/watch?v=4V_pouIbcnA
Verification of tube placement
 Auscultation (stomach first?) – bilateral to check





depth
Chest rise
Esophageal detection device
Colorimetric ETCO2 device
Continuous waveform capnography (“the most reliable
method”)
Record depth at teeth (average 21 cm in females, 22-23
cm in males)
Laryngoscopy techniques
Cormack-Lehane grading system
Laryngoscopy techniques
 BURP manuever (similar but different from Sellick’s
manuever or cricoid pressure)
 Backward
 Upward
 Rightward (patient’s right) Pressure
 Tends to improve the Cormack-Lehane grade
 Assistant may provide too much pressure, so you can
guide them
Laryngoscopy techniques
 Intubating stylets (Bougie)
 Using laryngoscope, insert flexible stylet between vocal
cords (grade 2) or above the arytenoids (grade 3)
 Slide ETT over the stylet into the trachea while keeping
laryngoscope in place