Principles of Airway Management, 3rd Edition

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Brendan T. Finucane, MBBCh, FRCPC Albert H. Santora, MD
Professor and Program Director Athens, Georgia, USA
Department of Anesthesiology and Pain Medicine
University of Alberta
Edmonton, Alberta, Canada
[email protected]

Library of Congress Cataloging-in-Publication Data

Finucane, Brendan T.
Principles of airway management / Brendan T. Finucane, Albert H. Santora.—3rd ed.
p. cm.
Includes bibliographical references and index.
ISBN 0-387-95530-5 (softcover : alk. paper)
1. Airway (Medicine) 2. Trachea—Intubation. 3. Respiratory intensive care. 4.
Anesthesiology. I. Santora, Albert H., 1952—II. Title.

RC732 .F56 2003

616.2—dc21 2002070729

ISBN 0-387-95530-5 Printed on acid-free paper.

© 2003 Springer-Verlag New York, Inc.

© Second Edition, 1996 by Mosby-Year Book, Inc., St. Louis, MO.

All rights reserved. This work may not be translated or copied in whole or in part with-
out the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth
Avenue, New York, NY 10010, USA), except for brief excerpts in connection with re-
views or scholarly analysis. Use in connection with any form of information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodol-
ogy now known or hereafter developed is forbidden.
The use in this publication of trade names, trademarks, service marks, and similar terms,
even if they are not identified as such, is not to be taken as an expression of opinion as
to whether or not they are subject to proprietary rights.
While the advice and information in this book are believed to be true and accurate at the
date of going to press, neither the authors nor the editors nor the publisher can accept any
legal responsibility for any errors or omissions that may be made. The publisher makes
no warranty, express or implied, with respect to the material contained herein.

Printed in the United States of America.

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Springer-Verlag New York Berlin Heidelberg

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 To
Pat and Donna Finucane
and
Mary and Crissy Santora
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Preface

Any man’s death diminishes me, because I am involved in Mankind

—John Donne

In 1988 Belhouse and Dore1 estimated that as many as 600 people died every
year from complications of airway management in the developed world. The
tragedy of this statistic was that most of these deaths were preventable. Infor-
mation on airway-related topics has increased exponentially since we published
the first edition of this book. In the past 10 years, almost 2000 English-language
publications have been published on airway management, reflecting an increase
in interest and change in this vitally important topic. We also have reason to be-
lieve that the number of deaths from airway mismanagement is declining at least
in North America (ASA Closed Claims Study).2
When we first conceived this book, our intended audience was medical stu-
dents. Then, we realized that other students and even seasoned practitioners of
airway techniques might also benefit from it. In addition, trainees in anesthesi-
ology, respiratory therapy, nurse anesthesia, as well as interns and residents in-
volved in acute-care activity and emergency medicine technicians would also
find much to learn. Thus, we published the second edition in 1996 with this ex-
panded target audience in mind.
Why is a third edition needed? Because there is no other concise, compre-
hensive textbook available on airway management. Further, the growing number
of publications on the subject indicates a growing interest in the field. Finally, it
is difficult to remain current in this field because of the rapid rate of change in
technology. It is difficult to imagine that the laryngoscope could be obsolete in
perhaps twenty years time. The advent of the laryngeal mask has changed the
practice of anesthesia, reduced the need for laryngoscopy and intubation, and
may partly explain the declining death rate from airway problems all over the
world.
This new edition has some important changes. We have expanded the discus-
sion in most of the chapters. In addition, the chapters on airway management and
CPR have been updated. The chapters on airway equipment, fiberoptic intuba-

vii
viii Preface

tion, the “difficult airway,” complications of airway management, and surgical

approaches to airway management have been significantly changed. We have
dedicated a new chapter to the laryngeal mask airway. The bibliography has been
expanded to include the most up-to-date citations, with a special emphasis on the
scientific aspects of airway management.
In the past two decades, the field of airway management has made great
progress. We do not consider ourselves authorities on every aspect of the sub-
ject, but we have learned a great deal about this topic in our 60 years or so of
combined experience. Anesthesiologists agree that there is no such thing as a
“simple anesthetic.” Similarly, there is no such thing as a “simple airway.” We
have all experienced the unheralded laryngeal spasm in the child emerging from
anesthesia and are impressed by the rapidity of desaturation in those cases. Air-
way management is the backbone of our specialty, and we have a responsibility
to disseminate the most up-to-date information to our colleagues on the front
lines, not just in anesthesia, but in all disciplines that deal with the airway.

Brendan T. Finucane, MBBCh, FRCPC

Albert H. Santora, MD

References
1. Belhouse CP, Dore C. Criteria for estimating likelihood of difficult endotracheal intu-
bation with the Macintosh laryngoscope. Anaes Intensive Care 1988;16:329-337.
2. ASA Closed Claims Project Lessons Learned. FW Cheney, MD; 1996 Annual Refresher
Course Lectures; Oct 19-23, 1996.
Acknowledgments

We would like to acknowledge Pat Crossley for her tireless efforts to meet im-
portant deadlines, Steve Wreakes for his excellent photography, Gisele Goudreau
and Marilyn Blake for their willingness to pose for photographs at short notice,
and Marilyn Blake for her secretarial support.

ix
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Contents

Preface vii
Acknowledgments ix

Chapter 1 Anatomy of the Airway 1

Chapter 2 Basic Airway Management and Cardiopulmonary

Resuscitation (CPR) 21

Chapter 3 Basic Airway Management Equipment 41

Chapter 4 Fiberoptic Airway Management Techniques 78

Chapter 5 Evaluation of the Airway 126

Chapter 6 Indications and Preparation of the Patient

for Intubation 162

Chapter 7 Techniques of Intubation 182

Chapter 8 The Difficult Airway 214

Chapter 9 Complications of Endotracheal Intubation 255

Chapter 10 Surgical Approaches to Airway Management

303

Chapter 11 The Pediatric Airway 380

Chapter 12 Mechanical Ventilation and Respiratory

Support 418

Chapter 13 The Laryngeal Mask Airway (LMA) 438

Index 491

xi
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1
Anatomy of the Airway

THE NOSE
ORAL CAVITY
Uvula
Tonsils
Tongue
Nerve supply to the tongue
PHARYNX
Prevertebral fascia
Retropharyngeal space
LARYNX
Laryngeal cartilages
Single cartilages
Paired cartilages
Laryngeal cavity
Piriform sinus
Nerve supply to the larynx
Superior laryngeal nerve
Recurrent laryngeal nerve
TRACHEA
COMPARATIVE ANATOMY OF THE ADULT
AND INFANT AIRWAYS
Head
Nose
Tongue
Larynx
Cricoid cartilage
Epiglottis
Trachea and mainstem bronchi
SUMMARY

Knowledge of anatomy is essential to the study of airway management. First,

anatomical considerations are helpful in diagnosing certain problems, such as the
position of a foreign body in a patient with airway obstruction. Second, since

1
2 1. Anatomy of the Airway

some procedures involved in establishing and maintaining an airway are per-

formed under emergency conditions, little if any time may be available for re-
viewing anatomy. Third, in many procedures involving the airway, such as in-
tubation, anatomical structures are only partially visible. As a result, one must
recognize not only the structures in view but also their spatial relationship to the
surrounding structures. This chapter reviews basic airway anatomy, discusses
some clinical correlates, and includes a comparison of the pediatric and adult
airway.

The Nose
The nose is a pyramidal-shaped structure projecting from the midface made up
of bone, cartilage, fibrofatty tissue, mucous membrane, and skin. It contains the
peripheral organ of smell and is the proximal portion of the respiratory tract. The
nose is divided into right and left nasal cavities by the nasal septum. The infe-
rior portion of the nose contains two apertures called the anterior nares. Each
naris is bounded laterally by an ala, or wing. The posterior portions of the nares
open into the nasopharynx and are referred to as choanae. One or both of these
apertures are absent in the congenital anomaly choanel atresia.1 Infants are com-
pulsive nose breathers at birth and therefore may suffocate if the condition is not
corrected.
The nose has a number of important functions, including: respiration, olefac-
tion, filtration, humidification, and is a reservoir for secretions from the paranasal
sinuses and the nasolacrimal ducts.
Anatomically, each side of the nose consists of a floor, a roof, and medial and
lateral walls. The septum forms the medial wall of each nostril and is made up
of perpendicular plates of ethmoid and vomer bones and the septal cartilage
(Fig 1.1). The bony plate forming the superior aspect of the septum is very thin
and descends from the cribriform plate of the ethmoid bone. The cribriform
plate may be fractured following trauma. Head injury victims should be ques-
tioned about nasal discharge, which may be cerebrospinal fluid (CSF). Nasal in-
tubation and the passage of nasogastric tubes are relatively contraindicated in the
presence of basal skull fractures.2 The lateral walls have a bony framework at-
tached to which are three bony projections referred to as conchae or turbinates
(Fig. 1.2). The upper and middle conchae are derived from the medial aspect of
the ethmoid; the inferior concha is a separate structure. There are a number of
openings in the lateral nasal walls that communicate with the paranasal sinuses
and the nasolacrimal duct.
A coronal section of the nose and mouth shows the location and relationships
of the nasal structures more clearly (Fig. 1.3). Considerable damage can be in-
flicted on the lateral walls of the nose by forcing endotracheal tubes into the nasal
cavity in the presence of an obstruction.
 The Nose 3

FIGURE 1.1. The nasal septum

(sagittal).

Nasal endotracheal tubes or airways should be well lubricated, and vasocon-

stricting solutions should be applied to the nasal mucosa before instrumentation.
When introducing a nasal endotracheal tube into the nostril, the bevel of the tube
should be parallel to the nasal septum (see Fig. 7.20, page 205) to avoid disrup-
tion of the conchae.

FIGURE 1.2. The lateral nasal wall.

4 1. Anatomy of the Airway

FIGURE 1.3. Coronal section through the nose and mouth.

Oral Cavity
The mouth, or oral cavity (Fig. 1.4), is divided into two parts: the vestibule and
the oral cavity proper. The vestibule is the space between the lips and the cheeks
externally and the gums and teeth internally. The oral cavity proper is bounded
anterolaterally by the alveolar arch, teeth, and gums; superiorly by the hard and
soft palates; and inferiorly by the tongue. Posteriorly, the oral cavity communi-
cates with the palatal arches and pharynx.

Uvula
In the posterior aspect of the mouth, the soft palate is shaped like an M, with the
uvula the centerpiece. This structure is a useful landmark for practitioners in-
volved in airway management.

Tonsils
The tonsils are collections of lymphoid tissue engulfed by two soft tissue folds,
pillars of the fauces. The anterior fold is called the palatoglossal arch, and the
posterior fold the palatopharyngeal arch (see Fig. 1.4). The lingual tonsil is made
up of lymphoid nodules found posterior to the sulcus terminalis and has a
cobblestone appearance. Hypertrophy of the lingual tonsil can cause airway
obstruction.3
 Oral Cavity 5

FIGURE 1.4. The oral cavity.

Tongue
The tongue is a muscular organ used for speech, taste, and deglutition. It is at-
tached to the hyoid bone, mandible, styloid processes, soft palate, and walls of
the pharynx. In an unconscious patient the oropharyngeal musculature tends to
relax and the tongue is displaced posteriorly, occluding the airway. Since the
tongue is the major cause of airway obstruction, it is an important anatomical
consideration in airway management. Its size in relation to the oropharyngeal
space is an important determinant of the ease or difficulty of tracheal intubation.

Nerve Supply to the Tongue

The sensory and motor innervation of the tongue is quite diverse and includes
fibers from a number of different sources.
Sensory fibers for the anterior two thirds are provided by the lingual nerve.
Taste fibers are furnished by the chorda tympani branch of the nervus intermedius
(from the facial nerve [VII]). Sensory fibers for the posterior third come from
the glossopharyngeal nerve (IX). In addition, some sensory innervation is pro-
vided by the superior laryngeal nerve (Fig. 1.5).
The Macintosh laryngoscope is inserted into the vallecula during laryngoscopy
and theoretically, at least, is less likely to elicit a vagal response because the in-
nervation of the vallecula is provided by the glossopharyngeal nerve. The Miller
blade, on the other hand, is advanced toward the inferior surface of the epiglot-
tis during laryngoscopy. The inferior surface of the epiglottis is innervated by
the superior laryngeal nerve. Therefore, one is more likely to encounter vagal
stimulation during laryngoscopy with a Miller blade.
6 1. Anatomy of the Airway

FIGURE 1.5. Sensory innervation of the tongue.

FIGURE 1.6. Nerve supply to the tongue.

 Pharynx 7

The major motor supply is from the hypoglossal nerve (XII) (Fig. 1.6), which
passes above the hyoid bone and is distributed to the lingual muscles. Since this
nerve is very superficial at the angle of the mandible, it is prone to injury dur-
ing vigorous manual manipulation of the airway.

Pharynx
The pharynx is a musculomembranous passage between the choanae and poste-
rior oral cavity and the larynx and esophagus. It extends from the base of the
skull to the inferior border of the cricoid cartilage anteriorly and the lower bor-
der of C6 posteriorly. It is approximately 15 cm long. Its widest point is at the
level of the hyoid bone and the narrowest at the lower end where it joins the
esophagus. Figures 1.7 and 1.8 should make it easier to visualize this structure.
In a normal conscious patient the gag reflex may be elicited by stimulating the
posterior pharyngeal wall. The afferent and efferent limbs of this reflex are me-
diated through the glossopharyngeal (IX) and vagus (X) nerves.

Prevertebral Fascia
The prevertebral fascia extends from the base of the skull down to the third tho-
racic vertebra, where it continues as the anterior longitudinal ligament. It also
extends laterally as the axillary sheath (Fig. 1.9). Abscess formation, hemorrhage

FIGURE 1.7. The pharynx (sagittal).