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Core Topics in Airway Management
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  • Cited by 1
  • 2nd edition
  • Edited by Ian Calder, National Hospital for Neurology and Royal London Hospital , Adrian Pearce, Guy's and St Thomas' Hospital, London
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Book description

Every anaesthetist reaches the end of their career with a collection of difficult airway experiences. Managing airway challenges relies on a combination of good clinical practice, knowledge of relevant basic sciences and critical evaluation of every aspect of airway care. This new edition of Core Topics in Airway Management provides any trainee or consultant involved in airway techniques with practical, clinically relevant coverage of the core skills and knowledge required to manage airways in a wide variety of patients and clinical settings. All new procedures and equipment are reviewed, and detailed chapters advise on airway issues in a range of surgical procedures. This edition also contains a series of practical questions and answers, enabling the reader to evaluate their knowledge. Written by leading airway experts with decades of experience managing difficult airways, Core Topics in Airway Management, 2nd edition is an invaluable tool for anaesthetists, intensivists, and emergency physicians.

Reviews

Review of the first edition:‘Core Topics in Airway Management concisely covers all the basics and some of the unique areas in airway management … Key, groundbreaking, clinically relevant material is presented in a clear and succinct manner, with salient points bulleted at the end of each chapter along with further reading suggestions … In summary, Core Topics in Airway Management is exactly what it says it is, a textbook that provides succinct and useful information on airway management that is required by a wide spectrum of health care professionals, independent of the reader's medical discipline or training level. This text provides a foundation for the multispecialty approach to airway management. Readers are offered an easy to read book on airway management, containing many pearls of practical wisdom.'

Carin Hagberg Source: Anesthesia and Analgesia

'I was impressed with the review of physiology and the willingness of editors and authors to describe areas of controversy in acute airway management … an excellent introduction to a central topic in anesthesiology and acute medicine.'

Source: Doody's Notes

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Contents


Page 1 of 2


  • Chapter 7 - Difficult airways: causation and identification
    pp 53-62
  • View abstract

    Summary

    This chapter offers a selective account of the functional anatomy of the adult head, neck and airway as it applies to anaesthetic clinical practice. The anatomy of both inside and outside of the nose has anaesthetic relevance. The epiglottis has evolved to shield the glottis not from anaesthetists, but from nutrients headed towards the stomach. As the trachea must run posteriorly from the glottis to reach the carina in the mediastinum, it is most superficial at its start. As the bronchial tree ramifies beyond the trachea, its initial divisions are crucially asymmetric. The position of the vein and other vessels, and indeed the trachea, can usefully be identified by ultrasound before cricothyroidotomy or tracheostomy. Mouth opening ability depends on craniocervical flexion/extension. The normal cervical spine is largely relevant only to the extent that it obstructs anaesthetists' access to the airway.
  • Chapter 9 - Facemasks and supraglottic airway devices
    pp 73-90
  • View abstract

    Summary

    Hypoxaemic hypoxia (airway obstruction) is more damaging to cells than anaemic or stagnant hypoxia. In order to fully understand the classification of hypoxia, it is useful to consider the example of carbon monoxide poisoning. It is known that hypoxaemic hypoxia is of particular importance in the development of cellular hypoxia and it goes without saying that, in the context of the difficult airway, the principal cause of hypoxaemia is airway obstruction. It is important to understand the mechanisms by which hypoxaemia develops, and the factors which determine the rate of this process. Causes of hypoxaemia occurring during anaesthesia can be divided into the following three categories: problems with O2 supply, problems with O2 delivery from lips to lung, and problems with O2 transfer from lung to blood. Pre-oxygenation aims to increase body O2 stores to their maximum, so that periods of apnoea are tolerated for longer before critical desaturation occurs.
  • Chapter 10 - Tracheal tubes, tracheostomy tubes
    pp 91-103
  • View abstract

    Summary

    This chapter discusses the fundamental thermodynamic concepts such as laminar flow and turbulent flow. Flow tends to be turbulent in upper airway obstruction, so gas density is influential. The functional anatomy of the upper airway can be reduced to a consideration of a collapsible segment (the pharynx) between two rigid segments (the nasopharynx and the trachea). This system behaves as a Starling resistor and airflow can become limited or completely abolished during spontaneous (negative intrathoracic pressure) breathing. Maintenance of pharyngeal airway patency is a complex neuromuscular phenomenon. In airway obstruction at the pharyngeal level, inspiratory flow may not be increased by increased inspiratory effort, but can be increased by positive pressure applied above the obstruction. The chapter describes the physics and function of a device which permitted ventilation of patients during bronchoscopy. There are a number of misconceptions regarding the operating principles of the Sanders injector.
  • Chapter 11 - Airway damage: iatrogenic and traumatic
    pp 104-109
  • View abstract

    Summary

    An increase in the sensitivity of airway reflexes during induction of anaesthesia increases the likelihood of laryngeal spasm and coughing. Some early work identified two types of receptor in the larynx: one a slowly adapting receptor and the second a rapidly adapting receptor thought to be especially sensitive to chemical stimulants. Anaesthetic agents may sensitise the receptors, explaining why some inhaled and intravenous agents may easily precipitate laryngeal spasm. Prior to the administration of lidocaine airway irritation caused not only the cough reflex, but also other respiratory reflexes such as expiration, apnoea and spasmodic panting. It should be noted that the initial application of local anaesthetic agents to the airway may be associated with laryngospasm. It is now thought that the pharyngeal dilators, in addition to the diaphragm, comprise the efferent output of the respiratory centre. Tonic contraction is required to keep the tongue forward and maintain airway patency.
  • Chapter 12 - Tracheal intubation: direct laryngoscopy
    pp 110-120
  • View abstract

    Summary

    Cross-infection may occur through reusable airway devices. The infective agent for transmissable spongiform encephalopathies (TSE) transmission is an abnormal prion protein. No prion-specific nucleic acid is involved in disease transmission, and abnormal prion-protein infectivity is not controlled by standard decontamination procedures of standard autoclaving or cold chemical sterilisation. A guideline on infection control within anaesthesia was published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in 2008 and provides valuable advice. There are three possible options for airway equipment, single use equipment, steam sterilisation or cold chemical sterilisation. Single use equipment eliminates the risk of cross-infection between patients through the airway device and is the preferred option. Repeated cycles of heat sterilisation will produce loss of transmitted light in rigid laryngoscope bundles. Cold chemical sterilisation is appropriate for devices which are not single use and are thermally sensitive. Automated disinfectors should be used for fibrescopes.
  • Chapter 13 - Tracheal intubation: flexible fibreoptic
    pp 121-137
  • View abstract

    Summary

    One of the ways of producing some structure to the way in which we think about managing normal and difficult airways is by algorithm or flow-chart. Sedation makes treatments such as endoscopies, tracheal intubation, dental treatment and minor surgical procedures more tolerable. Neuro-muscular blocking drugs (NMBS) are powerful drugs, indubitably dangerous in untrained hands. NMBDs make a vital contribution to patient safety; it is worth recalling what anaesthetic practice must have been like without them. The classic causes of acute airway obstruction include haematomas or tissue swelling after thyroid or anterior cervical spine or carotid surgery, trauma, or pharyngeal and laryngeal infections. Humans make errors, which in retrospect can seem distressingly obvious. Those involved in airway management need to appreciate that in critical situations there will not be time for detailed, analytical decision making, and be wary of fixating on issues or techniques that are not contributing to success.
  • Chapter 15 - Tracheal intubation: rigid indirect laryngoscopy
    pp 144-150
  • View abstract

    Summary

    This chapter discusses difficult airway, causes of difficulty, patient factors, and types of difficulties. One of the principal difficulties in predicting airway problems under anaesthesia is that in most unexpected cases there are no symptoms. The symptoms associated with obstructed sleep apnoea (OSA) syndrome should be sought in suspected cases. Anaesthetists should be aware of the symptomatology (and signs) of impending airway obstruction. The chapter briefs about special investigations such as 'Quick look' laryngoscopy, ultrasound and radiology. Sleep apnoea patients in particular may well be at greater risk in the postoperative period than at induction, whilst some types of surgery are notorious for engendering airway difficulty post-operatively; facio-maxillary and anterior cervical surgery are examples. Rheumatoid and acromegalic diseases of the larynx are particularly prone to post-extubation obstruction, so that the smallest possible size of tracheal tube should be used.
  • Chapter 16 - Misplacement of tracheal tubes
    pp 151-157
  • View abstract

    Summary

    Worldwide, obstructive sleep apnoea (OSA) is the most common medical disorder affecting sleep, afflicting about 3-4 percentage of the middle aged population of the UK, of whom about 70% are male. This chapter deals with the pathophysiology of the condition and its presenting features, investigations and treatment. Tonsillar hypertrophy should be recorded because this may be the underlying problem, and usually is so in children presenting with OSA. The gold standard of treatment for OSA is to submit the patient to nasal continuous positive airway pressure (nCPAP) whilst asleep. Although avoidance of sedative and opioid drugs during the peri-operative period is the recommended practice, sedatives and opioids have been used freely in conjunction with CPAP therapy without complication in the post-operative period. Post operative management involves nocturnal oxygen supply for at least one more night after opioid therapy has stopped.
  • Chapter 17 - Extubation
    pp 158-168
  • View abstract

    Summary

    Facemask anaesthesia may be suitable for airway maintenance for short anaesthetic procedures. Many anaesthesia facemasks are delivered with a multipronged o-ring around the collar of the connector. Maintenance of the patient's airway may be facilitated by use of an oropharyngeal or nasopharyngeal airway. Supraglottic airway devices (SADs) have several roles including anaesthesia, airway rescue after failed intubation or out of hospital use during cardiopulmonary resuscitation and as conduits to assist tracheal intubation. There are several classifications of SADs with most based on device anatomy and positioning. First generation SADs (e.g., classic laryngeal mask airway (cLMA)) are simply airway tubes, with no specific design features to improve safety (or ventilation efficacy). Second generation SADs include proseal laryngeal mask airway, the laryngeal tube suction II, LMA Supreme, streamlined liner of the pharynx airway (SLIPA) and combitube and easytubes. SADs are established methods for management of the difficult airway.
  • Chapter 18 - The aspiration problem
    pp 169-177
  • View abstract

    Summary

    This chapter concentrates on characteristics of the cuffed tube. With a cuffed tube, it is important that the insertion depth is sufficient to avoid inflating the cuff within the larynx itself. Cuffed tubes are generally used in adult practice to seal the airway to protect it from soiling from above and to prevent gas leaks. Three factors contribute to the extent of cuff induced tracheal damage: cuff characteristics, cuff pressure regulation, and cuff inflation technique and medium. Tracheal tubes are attached to the breathing system via tapered male to female 15 mm International Organization for Standardization (ISO) connectors. Tracheostomy tubes with a 15 mm ISO connector can be connected directly to a breathing circuit. Tube characteristics may influence the risk of ventilator-associated pneumonia (VAP). The chapter also reviews special tubes such as laser tubes, microlaryngoscopy tubes, and tubes for paediatric practice.
  • Chapter 19 - The lost airway
    pp 178-188
  • View abstract

    Summary

    Iatrogenic airway injury is mostly caused by laryngoscopy, visualisation of the laryngeal inlet, the placement of a tracheal tube and long-term intubation. Damage to teeth during laryngoscopy is the commonest cause of civil action against anaesthetists. Iatrogenic laryngeal trauma occurs mostly in patients undergoing routine, non-difficult, short-term tracheal intubation. Tracheal intubation-related neuropraxia of the lingual, hypoglossal, and laryngeal nerves have been described. Airway stenosis occurs at any level within the airway following tracheal intubation. Pharyngeal or oesophageal perforation is a serious complication of aerodigestive tract instrumentation, and is associated with a greater severity of injury and risk of mortality than other iatrogenic airway injuries. Trauma to the airway can be broadly classified into two types: external laryngeal trauma which includes blunt and penetrating injuries, and internal airway trauma which includes thermal, caustic and iatrogenic injuries. Non-iatrogenic airway trauma is rare but often life-threatening.
  • Chapter 20 - The airway in obstetrics
    pp 189-192
  • View abstract

    Summary

    Tracheal intubation is an essential skill but can be difficult and may result in complications, the most serious being hypoxaemic brain damage and death. A significant lifting force, causing considerable tissue distortion but not damage, may be required in direct laryngoscopy. The Macintosh technique of laryngoscopy depends on indirect elevation of the epiglottis and is the most frequently used direct laryngoscopy technique in most centres. Direct laryngoscopy with the straight laryngoscope was the first technique to allow tracheal intubation under vision. The straight laryngoscope offers unique advantages and there is good evidence of its value. The laryngoscope is inserted to the right of the midline and passed along the paraglossal gutter to the right side of the tongue. Many alternative techniques can facilitate tracheal intubation under vision in patients in whom this is not possible with direct laryngoscopy. Nasotracheal intubation is necessary when the oral route is not available.
  • Chapter 21 - The paediatric airway
    pp 193-202
  • View abstract

    Summary

    Understanding the equipment, knowledge of airway anatomy, good endoscopy skills, correct choice of tubes and railroading techniques are vital to the success of flexible fibreoptic intubation techniques. The modern day flexible fibreoptic scope consists of the following parts: body, insertion cord, light source, and camera and monitor. There are three ways in which an endoscopist can manipulate the tip of the fibrescope towards the desired target. These are advancement, tip deflection and rotation. Fibreoptic endoscopy involves guiding the tip of the fibrescope from the nose or the mouth into the trachea under continuous vision. The final stage of fibreoptic intubation involves railroading the tracheal tube and removing the fibrescope from the tube. Flexible fibreoptic intubation has revolutionised the management of patients with known anatomical airway difficulties. The practical fibreoptic techniques include awake fibreoptic intubation, asleep fibreoptic intubation, and retrograde fibreoptic intubation.

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