1. Airway Management
Carlos Rodriguez, MD
Assistant Professor
Department of Pediatric Anesthesiology

2. Evaluation of the Airway
 Size of upper incisors
 Relation of the maxillary and mandibular incisors at
mouth closure and with voluntary protrusion of lower
jaw
 Interincisor distance
 Visibility of the uvula
 Shape of the palate
 Thyromental distance
 Hyomental distance
 Length of neck
 Range of motion in the neck and head

3. Mallampati Classification
 Classification developed to grade the size of
the tongue in relation to the size of the oral
cavity
 Phonation FALSELY improves the view
 Class I: soft palate, tonsillar pillars, uvula
 Class II: tonsillar pillars and base of uvula
 Class III: soft palate
 Class IV: hard palate

4. Mallampati Classification
http://www.touchneurology.com/img/Image/Mallampati.gif

5. Positioning for Endotracheal Intubation
 Sniffing Position
 Elevation and extension of the patient’s head
 Goal is to align the oral, pharyngeal, and laryngeal axes
 May not be appropriate for younger patients
 Patient’s face should be near the practitioner’s
xyphoid cartilage
 Shoulder roll or ramp may be indicated
 External auditory meatus/sternal notch alignment

6. Bag Mask Ventilation
 Critical component of airway management
 Provides oxygenation and ventilation before
the placement of an airway
 Create a SEAL!!!!!!
 Use the thumb and index finger to hold the mask
to the face
 Other fingers hold the mandible
 Use jaw thrust to relieve obstruction
 Look for chest rise and fog within mask
 One-person vs Two-person ventilation
technique

7. Bag Mask Ventilation
 Large occiput in the pediatric population
leads to flexion of the neck in the
supine position
 Children have relatively larger tongues
 Leads to obstruction and possibility of
difficulty in ventilation

8. Airway Adjuncts
 Oral Airway
 Relieves obstruction created
by tongue/epiglottis
 Poorly tolerated in lightly
anesthetized patients
 Risk of damage to soft and
hard palate
 Nasal Airway
 Useful in patients after oral
surgery
 Better tolerated in awake
patients/less likely to gag
 Risk of epistaxis
 Contraindicated in patients
with basilar skull fractures
and coagulopathies
http://www.healthsystem.virginia.edu/internet/anesthesiology-elective/airway/equipment.cfm

9. Endotracheal Intubation
 Laryngoscope
 Held with the left hand
 Blade is inserted into the
right side of the mouth
 Blade deflects the tongue
to the left
 Avoid pressure on gums
and teeth
 USE forward and upward
movement
 AVOID lever movement
towards practitioner
http://www.laryngoscopes.net/

10. Endotracheal Intubation
 Miller Blade/Straight
Blade
 The blade passes
the epiglottis
 Elevation of the
epiglottis exposes
the glottic opening

11. Endotracheal Intubation
 Macintosh/Curved
Blade
 The blade is
advanced into the
vallecula
 Forward and upward
movement moves
epiglottis to reveal
glottic opening

12. Endotracheal Intubation
 Tube size is determined according to internal
diameter
 Lengthwise centimeter markings will guide
practitioner of depth placement
 Cuff vs No cuff
 Cuffs facilitate positive pressure ventilation and
help prevent the aspiration of gastric contents
 Appropriate size of tube:
 4 + Age/4 = tube diameter
 Estimate endotracheal length:
 12 + Age/2 = length of tube (in cm)

13. Endotracheal Intubation
 Confirmation of Tube Placement
 Clinical Assessment
 Auscultationof lung fields and over stomach
 Symmetric bilateral movement of chest
 Condensation within the endotracheal tube
 Monitors
 End-TidalCO2
 Pulse Oximetry

14. Endotracheal Intubation
 Glottic Opening
 Grade I: full view
 Grade II: posterior
portion visualized
 Grade III: Only the
tip of the epiglottis is
visible
 Grade IV: Only soft
palate is visible

15. LMA

16. Pediatric/Infant Anatomy
 Large and floppy epiglottis
 May lie against the posterior wall of the
pharynx
 Large tongue relative to the mandible
 Glottis lies higher and more anterior
 Vocal cords are angled more forwards
and downwards

17. LMA: Indications
 Routine Airway Management
 “as long as there is not a contraindication
to the use of the face mask”
 Difficult Airway Management
 Emergency Airway
 Conduit for Intubation

18. LMA: Contraindications
 Do NOT use as a substitute when the airway
MUST be guaranteed
 Reduced pulmonary compliance
 Patients with certain oral and periglottic pathology
 Situations when airway cannot be readily accessed
when dislodged
 Full stomach
 Nonfasted persons
 Morbidly obese
 Recent trauma
 GERD
 Intestinal obstruction

19. LMA
 How do we determine the size of LMA a
patient will need?

20. LMA Sizes
Size Weight
1 < 5 kg
1.5 5-10 kg
2 10-20 kg
2.5 20-30 kg
3 30-50 kg
4 50-70 kg
5 > 70 kg

21. Position
 Distal tip above the
esophageal sphincter
 Proximal aspect of
the mask juxtaposed
with the base of the
tongue
 Sides of the mask
facing the pyriform
fossae
 Inflated cuff creates a
low-pressure seal
around the periphery
of the laryngeal inlet

22. What is the optimal Cuff
Pressure?
 Recurrent laryngeal nerve injury
 Distorted pharyngeal anatomy- reduced
mucosal perfusion
 Postop stridor
 Sore throat and dysphagia
 Manufacturers recommend pressures
lower that 60 cmH2O

23. 40 cmH2O
 Schloss, et all- 2012
 >40cmH2O
 Sore throat
 Less efficient ventilation
 <40cmH2O
 Lower pressures lead to a better seal-
better to conform to the surrounding
hypopharynx
 Small inflation volumes can lead to
substantial increases in intracuff pressures

24. Laryngeal Mask Airway
 Alternative to
tracheal intubation
 Difficult Airway
Algorithm
 Placed blindly; cuff
is deflated with
opening facing
tongue
 Does not reliably
prevent aspiration of
gastric contents
http://www.anecare.com/Products/images/LMA-brief1.jpg;
http://www.oriontraining.co.uk/images/lma.jpg

25. Anesthesiology 2003; 98:1269 –77

26. The Difficult Airway
 Algorithm originated in 1993
 LMA added to algorithm in 2003
 Definition: “conventionally trained
anesthesiologist experiences difficulty
with intubation, mask ventilation or
both”

27. The Difficult Airway
 Disorders with Associated Airway
Problems
 Achondroplasia
 Arthrogryposis
 Beckwith-Wiedemann syndrome
 Cornelia de Lange syndrome
 Epidermolysis Bullosa
 Goldenhaar syndrome
 Pierre-Robin syndrome

28. The Difficult Airway
 Disorders with Associated Airway
Problems
 Treacher Collins syndrome
 Trisomy 21
 Turner syndrome
 Mucopolysaccharidoses
 Hunter
 Hurler

29. The Difficult Airway

30. The Difficult Airway
 Achondroplasia
 Midfacialhypoplasia
 Small nasal passages
 Small mouth
 Megacephaly
 Difficult mask
 Difficult intubation

31. The Difficult Airway
 Arthrogryposis
 Hypoplastic
mandible
 Cleft palate
 Torticollis
 Difficult intubation

32. The Difficult Airway
 Beckwith-
Widermann
syndrome
 Macroglossia
(smaller with age)
 Difficult intubation

33. The Difficult Airway
 Cornelia de Lange
syndrome
 High arch palate
 Micrognathia
 Large tongue
 Cleft palate
 Short neck
 Difficult intubation

34. The Difficult Airway
 Epidermolysis Bullosa
 Pressure lesions in
mouth and airway
 Possible microstomia
 Postoperative laryngeal
obstruction due to bulla
 Difficult intubation

35. The Difficult Airway

36. The Difficult Airway
 Goldenhaar syndrome
 Hypoplastic zygomatic
arch
 +/- cleft tongue, palate
 T-E fistula
 Macrostomia
 Mandibular hypoplasia
 Cervical spine defects
 Difficult intubation

37. The Difficult Airway
 Pierre-Robin syndrome
 Hypoplastic mandible
 Pseudo-macroglossia
 High arched palate
 Difficult intubation

38. The Difficult Airway

39. The Difficult Airway
 Treacher Collins syndrome
 Malar, mandibular hypoplasia
 Cleft lip
 Choanal atresia
 Macro or microstomia
 Difficult intubation
 Difficult ventilation

40. The Difficult Airway
 Trisomy 21
 Small mouth
 Hypoplastic mandible
 Protruding tongue
 C1-C2 instability
 Possible difficult
intubation and ventilation

41. The Difficult Airway
 Turner syndrome
 Narrow maxilla
 Small mandible
 Short neck
 Difficult intubation

42. The Difficult Airway
 Mucopolysaccharidoses
 Hurler
 Coarse facial features
 Macroglossia
 Short neck
 Tonsillar hypertrophy
 Narrowing of airways
 Difficult intubation