Benumof and Hagberg's Airway Management E-Book

Carin A. Hagberg

BOOK

Benumof and Hagberg's Airway Management E-Book

Carin A. Hagberg

(2012)

Additional Information

Book Details

ISBN: 978-1-4557-3810-6
Edition: 3
Language: English
Pages: 1088
Subjects: Anaesthetics
General surgery

Abstract

Enhance your airway management skills and overcome clinical challenges with Benumof and Hagberg's Airway Management, 3rd Edition. Trusted by anesthesiologists, residents, and nurse anesthetists, this one-of-a-kind anesthesiology reference offers expert, full-color guidance on pre- and post-intubation techniques and protocols, from equipment selection through management of complications.

Consult this title on your favorite e-reader with intuitive search tools and adjustable font sizes. Elsevier eBooks provide instant portable access to your entire library, no matter what device you’re using or where you’re located.

Practice with confidence by consulting the only reference exclusively dedicated to airway management, and trusted by anesthesiologists, residents, and nurse anesthetists for up-to-date information on every aspect of the field.
Focus on the most essential and practical information with a concise, how-to approach, carefully chosen illustrations, and case examples and analysis throughout.

Apply the latest know-how with new chapters on video laryngoscopes and airway management during CPR, plus comprehensive updates throughout from Dr. Carin Hagberg and many new contributing experts on airway management.
Select the most appropriate techniques for difficult cases using the latest ASA guidelines.
Gain a rich visual perspective on complex procedures and monitoring techniques with hundreds of new full-color illustrations throughout.
View videos of intubation and airway management procedures online at www.expertconsult.com, plus access the entire, searchable contents of the book.

Section Title	Page	Action	Price
Front cover	cover
Expert Consult page	FM1
Benumof and Hagberg's Airway Management	i
Copyright page	iv
Dedication	v
Contributors	vii
Foreword	xv
Preface	xvii
Acknowledgments	xix
Table of Contents	xxi
Video TOC	xxiii
1 Basic Clinical Science Considerations	1
1 Functional Anatomy of the Airway	3
I. Introduction	3
II. Upper Airway	3
A. Nose	3
B. Pharynx	5
1. Defense Against Pathogens	5
2. Upper Airway Obstruction	6
a. Sedation and Anesthesia	6
b. Obstructive Sleep Apnea	6
C. Larynx	8
1. Bones of the Larynx	8
2. Cartilages of the Larynx	8
a. Thyroid Cartilage	8
b. Cricoid Cartilage	9
c. Arytenoids	9
d. Epiglottis	10
e. Cuneiform and Corniculate Cartilages	11
f. False and True Vocal Cords	11
g. Laryngeal Cavity	11
3. Muscles, Innervation, and Blood Supply of the Larynx	11
a. Extrinsic Muscles of the Larynx	12
b. Intrinsic Muscles of the Larynx	12
c. Innervation of the Larynx	13
Glottic Closure and Laryngeal Spasm.	14
Vocal Cord Palsies.	14
d. Blood Supply of the Larynx	15
III. Lower Airway	15
A. Gross Structure of the Trachea and Bronchi	15
B. Airway Epithelium and Airway Defense Mechanisms	17
C. Blood Supply	18
D. Function of the Lower Airway	18
1. Forces Acting on the Airway	18
2. Relationship Between Structure and Function	19
IV. Conclusions	20
V. Clinical Pearls	20
Selected References	20
References	20.e1
2 Airway Imaging:	21
I. Introduction	21
II. Imaging Modalities	22
A. Conventional Radiography (Plain Film)	22
B. Computed Tomography	22
C. Magnetic Resonance Imaging	23
III. Basics of Plain Film Interpretation	23
A. Cervical Spine Radiography	23
1. General Technique, Anatomy, and Basic Interpretation	23
2. Pertinent Findings and Pathology	24
a. Pseudosubluxation and Pseudodislocation	24
b. Congenital and Developmental Anomalies	24
Occipital Fusion of C1.	24
Nonfusion of Anterior and Posterior Arches Of C1.	26
Pseudofractures of C2 and Dens.	26
Hypoplasia of C2.	27
c. Acquired Pathology	28
Cervical Spondylosis.	28
Inflammatory Arthropathies.	29
d. Anthropologic Measurements	30
B. Soft Tissue Neck Radiography	30
1. General Technique, Anatomy, and Basic Interpretation	30
2. Classic Plain Film Diagnosis	35
a. Acute Epiglottitis	35
b. Laryngotracheobronchitis or Croup	35
c. Foreign Body	35
C. Chest Radiography	35
1. General Technique	35
2. Interpretation of Pertinent Findings	36
a. Level of Diaphragm	36
b. Lung Aeration	36
c. Mediastinum and Heart	38
d. Tracheobronchial Tree	38
Endotracheal Tube Positioning.	38
Nasogastric Tube Positioning.	41
IV. Cross-Sectional Anatomy and Pathology: Computed Tomography and Magnetic Resonance Imaging	41
A. Midface	41
B. Nose and Nasal Cavity	42
1. Imaging Anatomy Overview	42
2. Pertinent Imaging Pathology	42
a. Congenital and Developmental Abnormalities	42
Congenital Choanal Stenosis and Atresia.	42
Deviated Septum.	43
Concha Bullosa.	44
b. Inflammatory Conditions	45
Rhinosinusitis.	45
Polyposis.	45
c. Trauma	45
d. Tumors and Other Conditions	46
Malignant Tumors.	46
Nonmalignant Destructive Tumors	48
Juvenile Nasopharyngeal Angiofibroma.	48
Wegener’s Granulomatosis.	48
Fibrous Dysplasia.	49
C. Oral Cavity	49
1. Imaging Anatomy Overview	49
2. Pertinent Imaging Pathology	53
a. Macroglossia	53
b. Micrognathia and Retrognathia	54
c. Exostosis	55
d. Tumors	56
D. Pharynx	56
1. Nasopharynx	57
a. Imaging Anatomy Overview	57
b. Pertinent Imaging Pathology	57
Adenoidal Hypertrophy.	57
Tornwaldt’s Cyst.	58
Infection and Abscess.	59
Tumors and Other Conditions.	59
2. Oropharynx	59
a. Imaging Anatomy Overview	59
b. Pertinent Imaging Pathology	60
Tonsillar Hypertrophy.	60
Tonsillitis and Peritonsillar Abscess.	61
Retropharyngeal Process.	61
Tortuous Internal or Common Carotid Artery.	62
Tumors and Other Conditions.	62
3. Hypopharynx	63
a. Imaging Anatomy Overview	63
b. Pertinent Imaging Pathology	64
Pharyngitis.	64
Pharyngocele.	64
Zenker’s Diverticulum.	64
Trauma	64
Hematomas.	64
Postradiation Changes.	64
Tumors and Other Conditions	64
Squamous Cell Carcinoma.	64
Lymphomas.	64
Other Malignancies.	65
E. Larynx	65
1. Imaging Anatomy Overview	65
2. Pertinent Imaging Pathology	68
a. Trauma	68
b. Vocal Cord Paralysis	69
c. Congenital Lesions	69
Laryngomalacia.	69
Webs and Atresias.	69
Stenosis.	69
d. Tumors and other Conditions	70
Benign Tumors.	70
Cysts and Laryngoceles.	70
Malignant Neoplasms.	70
F. Trachea	70
1. Imaging Anatomy Overview	71
2. Pertinent Imaging Pathology	71
a. Extrinsic Tracheal Pathology	71
Thyroid Goiter.	71
Thyroid Carcinoma and Nodes.	71
Vascular Rings and Slings.	71
b. Intrinsic Tracheal Pathology	71
Trauma.	71
Iatrogenic Injury.	72
c. Non-Neoplastic Tracheal Narrowing	74
Tracheomalacia.	74
Congenital Stenosis (Subglottic or Tracheal).	74
Tracheoesophageal Fistula.	74
d. Tumors and Other Conditions	74
V. ConclusionS	75
VI. Clinical Pearls	75
Selected References	75
References	75.e1
3 Ultrasonography in Airway Management	76
I. Introduction	76
II. The Ultrasound Image and how to Obtain It	76
III. Visualizing the Airway and the Adjacent Structures	77
A. Mouth and Tongue	77
B. Oropharynx	78
C. Hypopharynx	79
D. Hyoid Bone	79
E. Larynx	79
F. Vocal Cords	80
G. Cricothyroid Membrane and Cricoid Cartilage	81
H. Trachea	81
I. Esophagus	81
J. Lower Trachea and Bronchi	82
K. Peripheral Lung and Pleura	82
L. Diaphragm	82
IV. Clinical Applications	83
A. Prediction of Difficult Laryngoscopy in Surgical Patients	83
B. Evaluation of Pathology That May Influence the Choice of Airway Management Technique	83
C. Diagnosis of Obstructive Sleep Apnea	84
D. Evaluation of Prandial Status	84
E. Prediction of the Appropriate Diameter of an Endotracheal, Endobronchial, or Tracheostomy Tube	84
F. Localization of the Trachea	85
G. Localization of the Cricothyroid Membrane	85
H. Airway-Related Nerve Blocks	85
I. Confirmation of Endotracheal Tube Placement	85
J. Tracheostomy	87
K. Percutaneous Dilatational Tracheostomy	87
L. Confirmation of Gastric Tube Placement	88
M. Diagnosis of Pneumothorax	88
N. Differentiation Among Different Types of Lung and Pleura Pathology	88
O. Prediction of Successful Extubation	90
V. Special Techniques and Future Aspects	90
VI. Learning Ultrasonography	90
VII. ConclusionS	90
VIII. Clinical Pearls	90
Acknowledgments	91
Selected References	91
References	91.e1
4 Physics and Modeling of the Airway	92
I. the Gas Laws	92
A. Ideal Gases	92
B. Nonideal Gases: The van der Waals Effect	93
C. Diffusion of Gases	93
D. Pressure, Flow, and Resistance	93
E. Example: Analysis of Transtracheal Jet Ventilation	95
1. Analysis	95
II. Gas Flow	96
A. Laminar Flow	96
1. Laminar Flow Example	97
Answer:	97
B. Turbulent Flow	97
1. Reynolds Number Calculation Example	97
C. Critical Velocity	98
1. Critical Velocity Calculation Example	98
D. Flow Through an Orifice	98
1. Helium-Oxygen Mixtures	98
2. Clinical Vignettes	99
E. Pressure Differences	100
F. Resistance to Gas Flow	100
1. Endotracheal Tube Resistance	101
III. Work of Breathing	102
IV. Pulmonary Biomechanics	104
A. The Respiratory Mechanics Equation	104
1. The Pulmonary Time Constant	105
2. Determination of Rohrer’s Constants	105
3. Compliance	105
B. An Advanced Formulation of the Respiratory Mechanics Equation	106
V. Anesthesia at Moderate Altitude	106
A. Altered Partial Pressure of Gases	106
B. Oxygen Analyzers	106
C. Carbon Dioxide Analyzers and Vapor Analyzers	107
D. Vapors and Vaporizers	107
E. Flowmeters	107
F. Flowmeter Calibration	107
1. Example Calculation 1	107
2. Example Calculation 2	107
G. Anesthetic Implications	108
VI. Estimation of Gas Rates	108
A. Estimation of Carbon Dioxide Production Rate	108
B. Estimation of Oxygen Consumption Rate	108
C. Interpretation of Carbon Dioxide Production and Oxygen Consumption Rates	108
VII. Mathematical Modeling Related to the Airway	108
A. Overview	108
B. Background	109
C. Problems in Model Solving	109
D. Description of TK SOLVER	109
E. Example 1: Application of Mathematical Modeling to the Study of Gas Exchange Indices	109
1. Analysis	109
F. Example 2: Theoretical Study of Hemoglobin Concentration Effects on Gas Exchange Indices	111
G. Example 3: Modeling the Oxygenation Effects of P50 Changes at Altitude	111
H. Example 4: Mathematical/ Computer Model for Extracorporeal Membrane Oxygenation	112
I. Discussion	113
J. Utility	113
K. Software	115
L. Computational Flow Diagrams	115
VIII. Selected Dimensional Equivalents	116
IX. ConclusionS	116
X. Clinical Pearls	116
Selected References	117
References	117.e1
5 Physiology of the Airway	118
I. Normal Respiratory Physiology (Nonanesthetized)	118
A. Gravity-Determined Distribution of Perfusion and Ventilation	119
1. Distribution of Pulmonary Perfusion	119
2. Distribution of Ventilation	120
3. The Ventilation-Perfusion Ratio	121
B. Nongravitational Determinants of Blood Flow Distribution	123
1. Passive Processes	123
a. Cardiac Output	123
b. Lung Volume	123
2. Active Processes and Pulmonary Vascular Tone	124
a. Tissue (Endothelial- and Smooth Muscle–derived) Products	124
b. Alveolar Gases	125
c. Neural Influences on Pulmonary Vascular Tone	127
d. Humoral Influences on Pulmonary Vascular Tone	127
3. Alternative (Nonalveolar) Pathways of Blood Flow Through the Lung	128
C. Nongravitational Determinants of Pulmonary Compliance, Resistance, Lung Volume, Ventilation, and Work of Breathing	128
1. Pulmonary Compliance	128
2. Airway Resistance	129
3. Different Regional Lung Time Constants	130
4. Pathways of Collateral Ventilation	131
5. Work of Breathing	131
6. Lung Volumes, Functional Residual Capacity, and Closing Capacity	132
a. Lung Volumes and Functional Residual Capacity	132
b. Airway Closure and Closing Capacity	134
Patient with Normal Lungs.	134
Patients with Abnormal Lungs.	135
Measurement of Closing Capacity.	135
Relationship Between Functional Residual Capacity and Closing Capacity.	135
D. Oxygen and Carbon Dioxide Transport	136
1. Alveolar and Dead Space Ventilation and Alveolar Gas Tensions	136
2. Oxygen Transport	138
a. Overview	138
b. Oxygen-Hemoglobin Dissociation Curve	138
c. Effect of on Alveolar Oxygen Tension	140
d. Effect of and on Arterial Oxygen Content	141
e. Fick Principle	141
3. Carbon Dioxide Transport	142
4. Bohr and Haldane Effects	143
E. Pulmonary Microcirculation, Interstitial Space, and Fluid (Pulmonary Edema)	143
II. Respiratory Function during Anesthesia	145
A. Anesthetic Depth and Respiratory Pattern	145
B. Anesthetic Depth and Spontaneous Minute Ventilation	145
C. Preexisting Respiratory Dysfunction	146
D. Special Intraoperative Conditions	146
E. Mechanisms of Hypoxemia During Anesthesia	147
1. Equipment Malfunction	147
a. Mechanical Failure of Anesthesia Apparatus to Deliver Oxygen to the Patient	147
b. Improper Endotracheal Tube Position	147
2. Hypoventilation	147
3. Hyperventilation	147
4. Decrease in Functional Residual Capacity	147
a. Supine Position	148
b. Induction of General Anesthesia: Change in Thoracic Cage Muscle Tone	148
c. Paralysis	148
d. Light or Inadequate Anesthesia and Active Expiration	148
e. Increased Airway Resistance	149
f. Supine Position, Immobility, and Excessive Intravenous Fluid Administration	149
g. High Inspired Oxygen Concentration and Absorption Atelectasis	150
h. Surgical Position	150
Supine Position.	150
Lateral Decubitus Position.	150
i. Ventilation Pattern (Rapid Shallow Breathing)	150
j. Decreased Removal of Secretions (Decreased Mucociliary Flow)	151
5. Decreased Cardiac Output and Increased Oxygen Consumption	151
6. Inhibition of Hypoxic Pulmonary Vasoconstriction	151
7. Paralysis	152
8. Right-to-Left Interatrial Shunting	152
9. Involvement of Mechanisms of Hypoxemia in Specific Diseases	152
F. Mechanisms of Hypercapnia and Hypocapnia During Anesthesia	153
1. Hypercapnia	153
2. Hypoventilation	153
3. Increased Dead Space Ventilation	153
4. Increased Carbon Dioxide Production	154
5. Inadvertent Switching Off of a Carbon Dioxide Absorber	154
6. Hypocapnia	154
G. Physiologic Effects of Abnormalities in Respiratory Gases	154
1. Hypoxia	154
2. Hyperoxia (Oxygen Toxicity)	155
3. Hypercapnia	156
4. Hypocapnia	157
III. Conclusions	157
IV. Clinical Pearls	158
Selected References	158
References	158.e1
6 Airway Pharmacology	159
I. Introduction	159
II. Airway Pharmacology in Normal Airway Physiology	160
A. Clinical Issues	160
1. Airway Patency	160
2. Airway Protection	160
3. Airway Reactivity	160
4. Adverse Reactions	160
5. Optimizing Conditions for Instrumentation of the Airway	160
6. Management of the Obstructed Airway	160
B. Physiology of the Upper Airway	160
1. Anatomy	160
2. Neuromuscular Function	161
3. Autonomic Nervous System	161
4. Voluntary Regulation of Airway Patency	161
5. Disease	161
C. Effects of Drugs on the Airway	161
1. Direct Effect	161
2. Indirect Effect	161
III. Drugs with a Direct Effect on the Airway	161
A. Local Anesthetics	161
1. Complications of Airway Local Anesthesia	162
2. Specific Local Anesthetic Agents	162
a. Lidocaine	162
b. Bupivacaine	162
c. Benzocaine	162
d. Cocaine	162
B. Sympathomimetics	162
C. Inhaled Volatile Agents	163
IV. Drugs with an Indirect Effect on the Airway	163
A. Sedatives and Upper Airway Patency	163
B. Effect of Sedatives on Airway Reactivity and Airway Protection	164
C. Sedatives and the Potential to Produce Apnea	164
D. Sedatives and the Lower Airway	164
E. Opioid Analgesics and the Airway	164
F. Neuromuscular Blockade and the Airway	165
G. Other Drugs with Indirect Effect on the Upper Airway	166
V. Airway Pharmacology for the Treatment of Asthma	166
A. Overview	166
1. Diagnosis	167
2. Prevalence	167
3. Distribution	167
4. Pathology	167
a. Airflow Limitation	167
b. Hyperreactivity	167
c. Inflammation	167
d. Remodeling	168
5. Treatment of Asthma	168
6. Routes of Drug Delivery	169
B. Drug Treatments for Asthma	169
1. β-Adrenoceptor Agonists	170
a. Pharmacodynamics	170
Duration of Action.	171
Adverse Effects.	171
b. Pharmacokinetics	171
c. Utility	171
2. Glucocorticoids	172
a. Pharmacodynamics	172
b. Pharmacokinetics	173
c. Utility	173
3. Methylxanthines	173
a. Pharmacodynamics	174
b. Pharmacokinetics	174
c. Utility	174
4. Leukotriene Modifiers	175
2 The Difficult Airway: Definition, Recognition, and the ASA Algorithm	199
8 Definition and Incidence of the Difficult Airway	201
I. Introduction	201
II. Definition and Classification of the Difficult Airway	201
A. Difficult or Impossible Face Mask Ventilation	202
1. Causes of Difficult Mask Ventilation	202
2. Definition of Difficult Mask Ventilation	202
3. Incidence of Difficult Mask Ventilation	203
B. Difficulties with Supraglottic Airway Devices	203
1. Definition of Difficult Placement	203
2. Incidence of Success	203
C. Difficult Direct Laryngoscopy	204
1. Laryngeal Visualization	204
2. Incidence of Difficult Laryngeal Visualization	204
D. Difficult Intubation During Direct Laryngoscopy	205
1. Incidence of Difficult Intubation	205
2. Combined Difficult Mask Ventilation and Difficult Intubation	205
3. Impossible Mask Ventilation and Intubation	205
4. Variability in Incidence of Difficult Laryngoscopy and Difficult Intubation	205
5. Complications of Difficult Laryngoscopy and Difficult Intubation	206
E. Difficult Video Laryngoscopy	206
F. Difficult Flexible Bronchoscopic Intubation	206
1. Definition of Difficult Flexible Bronchoscopic Intubation	206
2. Incidence of Difficult or Failed Flexible Bronchoscopic Intubation	207
III. Conclusions	207
IV. Clinical Pearls	207
Selected References	207
References	208.e1
9 Evaluation and Recognition of the Difficult Airway	209
I. Introduction	209
II. Problematic Ventilation by Traditional Face Mask	210
III. Problematic Intubation by Traditional Laryngoscopy	210
A. Sniffing Position	210
B. Mouth Opening	211
C. Dentition	211
D. Tongue	212
IV. Special Situations	213
A. Morbid Obesity	213
B. Pregnancy	214
C. Lingual Tonsil Hypertrophy	215
D. Burns	215
E. Acromegaly	216
F. Epiglottitis	216
G. Acute Submandibular Space Cellulitis	216
H. Rheumatoid Arthritis	217
V. Reliability of Prediction Criteria	217
VI. Nontraditional Considerations in Difficult Airway Prediction	219
A. Imaging	219
B. Supraglottic and Glottic Tumors	220
C. Radiation Changes	220
D. Arthritis	220
E. Cancerous Goiter	220
F. Offsetting Features	220
G. Interobserver Variation	220
H. Anesthetic Technique	220
VII. ConclusionS	221
VIII. Clinical Pearls	221
Selected References	221
References	221.e1
10 The ASA Difficult Airway Algorithm:	222
I. Introduction	222
II. the ASA Difficult Airway Algorithm	223
A. Patient Evaluation and Risk Assessment	223
B. Difficult Bag-Mask Ventilation	226
C. Awake Tracheal Intubation	226
D. Difficult Intubation in the Unconscious or Anesthetized Patient	227
E. The “Cannot Intubate, Cannot Ventilate” Scenario	228
F. Extubation of a Patient with a Difficult Airway	228
G. Follow-up Care of a Patient with a Difficult Airway	228
III. Summary of the ASA Algorithm	229
IV. Problems with the ASA Algorithm and Likely Future Directions	229
A. Terminology in the ASA Difficult Airway Algorithm	230
B. Definition of Optimal-Best Attempt at Conventional Laryngoscopy	230
C. Definition of Optimal-Best Attempt at Conventional Mask Ventilation	231
D. Options for the CICV Scenario	231
E. Determinants of the Use of Muscle Relaxants for Difficult Airway Management	231
F. Summary	232
V. Introduction of A New comprehensive Airway Algorithm	232
A. The Main Algorithm	233
1. The Nonpredicted Difficult Airway	234
2. New Algorithm Pathways	235
a. Pathway A	235
b. Pathway B	236
c. Pathway C	236
d. Pathway D	236
e. Pathway E	237
B. Shortcomings of the New Airway Algorithm	237
C. Bloody Airways	238
D. Summary	238
VI. Conclusions	238
VII. Clinical Pearls	238
Selected References	239
References	239.e1
3 Preintubation-Ventilation Procedures	241
11 Preparation of the Patient for Awake Intubation	243
I. Background	243
A. History	243
B. Awake Intubation in Management of the Difficult Airway	244
C. Indications for Awake Intubation	244
II. the Preoperative Visit	244
A. Reviewing Old Charts	244
B. The Patient Interview	245
III. Preoperative Preparations	245
A. Transport	245
B. Staff	246
C. Monitors	246
D. Supplemental Oxygen	246
E. Airway Equipment	246
IV. Premedication and Sedation	247
A. Antisialagogues	247
1. Atropine	247
2. Glycopyrrolate	247
3. Scopolamine	247
B. Nasal Mucosal Vasoconstrictors	247
C. Aspiration Prophylaxis	247
1. Histamine Receptor Blockers	247
2. Proton Pump Inhibitors	248
3. Metoclopramide	248
D. Sedatives/Hypnotics	248
1. Benzodiazepines	248
a. Midazolam	248
b. Diazepam and Lorazepam	248
c. Precautions	248
2. Opioids	248
a. Fentanyl	249
b. Sufentanil	249
c. Alfentanil	249
d. Remifentanil	249
e. Precautions	249
3. Intravenous Anesthetics	249
a. Propofol	249
b. Dexmedetomidine	250
c. Ketamine	250
d. Droperidol	250
V. Topicalization	251
A. Lidocaine	251
B. Cocaine	251
C. Other Local Anesthetics	251
D. Application Techniques	252
1. Atomizers	252
2. Nebulizers	253
3. “Spray-As-You-Go”	253
VI. Nerve Blocks	254
A. Nasal Cavity and Nasopharynx	254
1. Anatomy	254
2. Nasal Pledgets or Nasopharyngeal Airways	254
3. Sphenopalatine Nerve Block	255
a. Oral Approach	255
b. Nasal Approach	255
4. Anterior Ethmoidal Nerve Block	256
B. Oropharynx	256
1. Anatomy	256
2. Glossopharyngeal Nerve Block	257
a. Posterior Approach (Palatopharyngeal Fold)	257
b. Anterior Approach (Palatoglossal Fold)	257
c. External Approach (Peristyloid)	258
C. Larynx	258
1. Anatomy	258
2. Superior Laryngeal Nerve Block	259
a. External Approach	259
Greater Cornu of the Hyoid.	260
Superior Cornu of the Thyroid.	260
Thyroid Notch.	260
b. Internal Approach	260
3. Cautions, Complications, and Contraindications	260
D. Trachea and Vocal Cords	261
1. Anatomy	261
2. Translaryngeal (Transtracheal) Anesthesia	261
a. Positioning and Landmarks	261
b. Technique	261
c. Cautions, Complications, Contraindications	262
VII. Conclusions	262
VIII. Clinical Pearls	263
Selected References	263
References	264.e1
12 Aspiration Prevention and Prophylaxis:	265
I. Perioperative Aspiration	265
A. Incidence	265
B. Consequences	266
C. Risk Factors	266
1. Demographic	266
2. Obesity	267
3. Systemic Diseases	267
4. Pregnancy	267
5. Pain and Analgesics	267
6. Positioning	268
D. Pathophysiology	268
E. Determinants of Morbidity	269
1. pH and Volume of Aspirate	269
2. Particulate Matter	269
II. Prevention of Aspiration	269
A. Preoperative Fasting	270
1. Pediatric Patients	270
2. Adult Patients	270
3. Pregnant Patients	271
B. Preinduction Gastric Emptying	272
C. Rapid-Sequence Induction and Cricoid Pressure	273
III. Medical Prophylaxis of Aspiration	274
A. Gastroesophageal Motility	274
1. Metoclopramide	275
2. Erythromycin	276
B. Reduction of Gastric Acid Content	276
1. Neutralization of Gastric Acid	276
2. Inhibition of Gastric Acid Secretion	276
a. H2-Receptor Blockade	276
Cimetidine.	276
Ranitidine.	277
Others.	278
b. Proton Pump Inhibition	278
IV. Conclusions	278
V. Clinical Pearls	279
Selected References	279
References	279.e1
13 Preoxygenation	280
I. Historical Perspective	280
II. Body Oxygen Stores	281
III. Physiology of Apnea and Apneic Mass-Movement Oxygenation	282
IV. Efficacy and Efficiency of Preoxygenation	282
A. Efficacy of Preoxygenation	283
1. Fraction of Inspired Oxygen	284
2. Duration of Breathing, Functional Residual Capacity, and Alveolar Ventilation	285
B. Efficiency of Preoxygenation	285
V. Techniques of Preoxygenation	286
A. Tidal Volume Breathing	286
B. Deep Breathing Techniques	286
VI. Breathing Systems for Preoxygenation	288
VII. Special Situations	290
A. Pregnant Patients	290
B. Morbidly Obese Patients	291
C. Elderly Patients	291
D. Patients with Lung Disease	292
E. Pediatric Patients	292
F. Tracheobronchial Suctioning	293
1. Guidelines for Suctioning	295
a. Open Endotracheal Suctioning	295
b. Closed-System Endotracheal Suctioning	295
G. “Routine” Preoxygenation Before Induction, During Recovery from Anesthesia, and in Critically Ill Patients	295
VIII. Conclusions	296
IX. Clinical Pearls	296
Selected References	297
References	297.e1
4 The Airway Techniques	299
14 Oxygen Delivery Systems, Inhalation Therapy, and Respiratory Therapy	301
I. Introduction	301
II. Oxygen Therapy	301
A. Indications	301
B. Oxygen Delivery Systems	303
1. Low-Flow Oxygen Systems	303
2. High-Flow Oxygen Systems	304
C. Oxygen Delivery Devices	304
1. Low-Flow Devices	304
a. Nasal Cannulas	304
b. Simple Face Mask	305
c. Partial Rebreathing Mask	305
d. Nonrebreathing Mask	305
e. Tracheostomy Collars	306
2. High-Flow Devices	306
a. Venturi Masks	306
b. High-Flow Nasal Cannulas	307
c. Aerosol Masks and T-Pieces with Nebulizers or Air-Oxygen Blenders	308
D. Humidifiers	308
E. Manual Resuscitation Bags	309
F. Complications	309
III. Techniques of Respiratory Care	310
A. Suctioning	311
1. Indications	311
2. Equipment	311
3. Technique	311
4. Complications	312
B. Chest Physical Therapy	312
1. Postural Drainage and Positional Changes	312
2. Percussion and Vibration Therapy	314
3. Incentive Spirometry	314
C. Intermittent Positive-Pressure Breathing	315
1. Indications	315
2. Administration	316
D. Noninvasive Ventilation	316
1. Indications	316
2. Limitations	317
IV. Inhalation Therapy	317
A. Basic Pharmacologic Principles	317
B. Aerosolized Drug Delivery Systems	317
C. Pharmacologic Agents	319
1. Mucokinetic Drugs	319
a. Hypoviscosity Agents	319
b. Mucolytic Agents	319
2. Bronchodilators and Antiasthmatic Drugs	320
a. Sympathomimetics	320
b. Anticholinergic Agents and Antibiotics	320
c. Antiallergy and Asthmatic Agents	322
V. Conclusions	322
VI. Clinical Pearls	322
Acknowledgements	323
Selected References	323
References	323.e1
15 Nonintubation Management of the Airway:	324
I. Overview	324
A. Upper Airway Anatomy and Physiology	324
B. Upper Airway Obstruction	325
1. Pharyngeal Obstruction	325
2. Hypopharyngeal Obstruction	326
3. Laryngeal Obstruction	327
4. Clinical Recognition of Upper Airway Obstruction	327
II. Nonintubation Approaches to Establish Airway Patency	327
A. Simple Maneuvers for the Native Airway	327
1. Head Tilt-Chin Lift	327
2. Jaw Thrust	327
3. Heimlich Maneuver	327
B. Artificial Airway Devices	328
1. Oropharyngeal Airways	328
2. Nasopharyngeal Airways	331
III. Nonintubation Approaches to Ventilation: Mask Ventilation	333
A. Face Mask Design and Techniques for Use	333
B. Controlled Ventilation by Face Mask	335
1. Anesthesia Circle System	335
2. Resuscitator Bags	336
C. Determining the Effectiveness of Mask Ventilation	336
IV. Nonintubation Airway Maintenance in Specific Clinical Scenarios	337
A. Sedation Anesthesia	337
B. Transitional Airway Techniques for Endotracheal Intubation and Extubation	337
C. General Anesthesia by Mask Airway	337
1. Intravenous Induction	337
2. Inhalation Induction	338
V. Choosing an Airway Technique	338
VI. Conclusions	338
VII. Clinical Pearls	338
Selected References	339
References	339.e1
16 Indications for Endotracheal Intubation	340
I. Introduction	340
II. Endotracheal Intubation for Resuscitation	340
III. Endotracheal Intubation for Prehospital Care	341
IV. Endotracheal Intubation for Emergency Medicine	341
V. Endotracheal Intubation for Intensive Care	342
VI. Endotracheal Intubation for Anesthesia	343
VII. Conclusions	344
VIII. Clinical Pearls	344
Selected References	345
References	345.e1
17 Laryngoscopic Orotracheal and Nasotracheal Intubation	346
I. A Short History of Endotracheal Intubation	346
II. Laryngoscopic Orotracheal Intubation	347
A. Preparation and Positioning	347
B. Preoxygenation	349
C. Laryngoscopy	350
D. Endotracheal Tube	353
E. Verification of Correct Placement	354
F. Securing the Endotracheal Tube	355
III. Laryngoscopic Nasotracheal Intubation	355
A. Preparation	356
B. Laryngoscopy	356
C. Endotracheal Intubation	357
D. Securing the Endotracheal Tube	357
IV. Conclusions	357
V. Clinical Pearls	357
Selected References	358
References	358.e1
18 Blind Digital Intubation	359
I. History	359
II. Indications	359
III. Technique of Digital Intubation	360
A. Preparation	360
B. Positioning	360
C. Technique	360
D. Tracheal Introducer–Assisted Digital Intubation	361
E. Neonatal Digital Intubation	362
F. Combined Techniques	362
IV. Case History	362
V. Limitations	363
VI. Conclusions	363
VII. Clinical Pearls	363
Selected References	363
References	364.e1
19 Fiberoptic and Flexible Endoscopic-Aided Techniques	365
I. Introduction and Historical Background	366
II. Flexible Fiberoptic and Non-Fiberoptic Bronchoscope Design and Care	367
A. Fiberoptic Bronchoscope Design	367
B. Fiberoptic Bronchoscope Cleaning	369
C. Disposable Flexible Bronchoscopes	371
1. Sheathed Fiberoptic Bronchoscope	371
2. Non-fiberoptic Flexible Bronchoscope	371
III. Rationale for Fiberoptic Intubation	371
A. Indications for Flexible Fiberoptic or Endoscopic Intubation	372
B. Contraindications: Absolute, Moderate, and Relative	372
IV. Equipment	373
A. Fiberoptic and Non-fiberoptic Bronchoscope Model Details	373
B. Fiberoptic Bronchoscope Cart	373
C. Ancillary Equipment	373
1. Bronchoscopy Swivel Adapters and Endoscopy Masks	373
2. Intubating Oral Airways	374
3. Short, Soft Nasopharyngeal Airways	375
4. Endotracheal Tubes	375
V. Clinical Techniques of Fiberoptic Intubation	376
A. Oral Fiberoptic Intubation of the Conscious Patient	376
1. Equipment, Monitoring, and Drug Availability	376
2. Psychological Preparation of the Patient	376
3. Rationale for Pharmacologic Therapy	377
B. Respiratory Monitoring Methods	377
C. Sedation and Analgesia	377
D. Local Anesthesia Purposes and Preparedness	378
1. Innervation of Orotracheal Airway Structures	378
2. Topical Orotracheal Anesthesia Techniques	378
a. Glossopharyngeal Anesthesia	378
b. Alternative Methods of Intraoral Anesthesia	378
c. Superior Laryngeal Nerve Block	379
5 Difficult Airway Situations	683
33 Prehospital Airway Management	685
I. Introduction	685
II. History of Airway Management by Emergency Medical Services	685
III. Prehospital Care of Airway Patients	686
A. Basic Airway Management	686
B. Extraglottic Airway Devices	686
IV. System Structure and Types of Providers	687
A. Emergency Medical Technicians	687
B. Advanced Emergency Medical Technicians	687
C. Paramedics	687
V. Physician Oversight and Continuous Quality Assurance	688
A. Training	688
B. Continuous Quality Improvement	688
VI. Conclusions	688
VII. Clinical Pearls	688
Selected References	691
References	691.e1
34 Disaster Preparedness, Cardiopulmonary Resuscitation, and Airway Management	692
I. Introduction	692
II. Disaster Triage	693
III. Surge Capacity	693
IV. Altered Standards of Care	694
V. Hospital Incident Command System	694
VI. Operating Room Preparation	694
VII. Anesthetic and Resuscitation Techniques	694
A. Emergency Airway Management and Ventilation	694
B. Anesthetic Techniques	694
VIII. Planning and Preparation	695
A. The U.S. National Disaster System	696
B. National Disaster Medical System Teams	696
C. Strategic National Stockpile	696
D. Surgical Specialty Teams	696
E. Infrastructure Resiliency	696
F. Anticipating Surprise	696
G. Decontamination, Personal Protective Equipment, and Isolation for Chemical, Biologic, and Radiologic Events	696
IX. Basic Life Support and Cardiopulmonary Resuscitation Guidelines	697
X. Initial Airway Management during Cardiopulmonary Resuscitation	697
A. Rescue Breathing	697
B. Airway Adjuncts	697
XI. Advanced Airway Management during Cardiopulmonary Resuscitation	698
A. Confirmation of Endotracheal Tube Placement During Cardiopulmonary Resuscitation	698
B. Use of Cricoid Pressure During Cardiopulmonary Resuscitation	701
C. Supraglottic Airway Devices	701
D. Role of Advanced Airway Devices	701
XII. Alternative Methods of Oxygen Delivery during Cardiopulmonary Resuscitation	701
A. Oxylator	701
B. ResQPOD	701
C. Passive Oxygen Insufflation	702
XIII. Challenges of Airway Management during Cardiopulmonary Resuscitation	702
A. Access to the Airway	702
B. Cervical Spine Injury	702
C. Equipment Challenges	703
XIV. Controversies	703
A. Role of Hyperventilation	703
B. When to Secure the Airway	703
XV. Conclusions	703
XVI. Clinical Pearls	703
Selected References	704
References	704.e1
35 The Patient with a Full Stomach	705
I. Introduction	705
II. Definition of Pulmonary Aspiration	705
III. Timing of Pulmonary Aspiration	706
IV. Physiologic Risk Factors in the Perioperative Patient	706
A. Gastric Volume and pH	706
B. Delayed Gastric Emptying	707
C. Impaired Protective Physiologic Mechanisms	707
1. Lower Esophageal Sphincter Tone	707
2. Upper Esophageal Sphincter Tone	707
D. Loss of Protective Laryngeal-Pharyngeal Airway Reflexes	707
V. Patients at Risk for Pulmonary Aspiration	707
VI. Perioperative Anesthesia Considerations in Full-Stomach Patients	708
A. Preoperative Fasting	708
1. Liquids	709
a. Clear Liquids	709
b. Milk	709
2. Solids and Nonhuman Milk	709
3. Patients with Diabetes	709
4. Ambulatory Patients and Anxiety	709
B. Fasting Guidelines Summary	710
C. Role of Preoperative Ultrasonography	710
D. Pharmacotherapy	710
E. Preoperative Gastric Emptying	710
1. Preoperative Gastric Tube Insertion Before Emergency Surgery	710
2. In Situ Gastric Tube During Induction	711
3. Effects of Gastric Tube Placement in Mechanically Ventilated Patients	711
4. Sealing the Esophagus by Inflatable Cuffs	711
VII. General Anesthesia Management	711
A. Awake Tracheal Intubation in Patients at High Risk for Pulmonary Aspiration	711
B. Rapid-Sequence Induction	712
1. Modified Rapid-Sequence Induction	713
2. Cricoid Pressure	713
a. Head and Neck Position	714
b. Timing of Cricoid Pressure Application	714
c. Single-Handed Cricoid Pressure	714
d. Double-Handed Cricoid Pressure	714
e. Cricoid Pressure in Clinical Practice	714
VIII. Management of the Difficult Airway in the Full-Stomach Patient	714
A. Difficult Airway Management Using the Laryngeal Mask Airway	715
1. Classic Laryngeal Mask Airway	715
2. Fastrach Intubating Laryngeal Mask Airway	717
3. ProSeal Laryngeal Mask Airway	717
B. Esophageal-Tracheal Combitube in the Full-Stomach Patient	718
C. Esophageal-Tracheal Combitube for Prevention of Pulmonary Aspiration	719
D. King Laryngeal Tube Suction Airways in the Full-Stomach Patient	720
IX. Extubation	720
X. Management of Pulmonary Aspiration	720
XI. Conclusions	721
XII. Clinical Pearls	722
Selected References	722
References	722.e1
36 The Difficult Pediatric Airway	723
I. Introduction	724
II. Anatomy of the Pediatric Airway	724
A. Larynx	724
B. Epiglottis	724
C. Subglottis	724
III. Evaluation of the Pediatric Airway	724
A. Diagnostic Evaluation	725
IV. Classification of the Difficult Pediatric Airway	725
V. Pediatric Airway Equipment	725
A. Face Mask	726
B. Oropharyngeal Airway	726
C. Nasopharyngeal Airway	726
D. Endotracheal Tube	726
E. Endotracheal Tube Exchangers	727
F. Laryngoscopes	727
1. Straight vs. Curved Blades	727
2. Oxyscope	727
3. Anterior Commissure Laryngoscope	727
4. Bullard Laryngoscope	727
5. Angulated Video-Intubation Laryngoscope	728
6. Truview Laryngoscope	728
7. GlideScope Video Laryngoscope	728
8. Airtraq Optical Laryngoscope	728
G. Stylets	728
1. Lighted Stylets	729
2. Optical Stylets	729
3. Video-Optical Intubation Stylet	729
H. Laryngeal Mask Airways	730
1. LMA Family	730
2. Air-Q Intubating Laryngeal Airway	730
I. Rigid Ventilating Bronchoscope	731
VI. Induction Technique	731
VII. Airway Management Techniques	731
A. Techniques for Ventilation	731
B. Techniques for Intubation	731
1. Direct Laryngoscopy	731
2. Blind Intubation Technique	732
a. Blind Nasotracheal Intubation	732
b. Digital Endotracheal Intubation	732
c. Lightwand Intubation	732
3. Fiberoptic Laryngoscopy	732
4. Bullard Laryngoscope	734
5. Dental Mirror–Assisted Laryngoscopy	734
6. Retrograde Intubation	734
7. Emergency Access	734
VIII. Complications of Airway Management	734
IX. Airway Diseases and Implications	735
A. Head Anomalies	735
1. Airway Implications	735
2. Specific Anomalies	735
a. Encephalocele	735
b. Hydrocephalus	735
c. Mucopolysaccharidoses	735
B. Facial Anomalies: Maxillary and Mandibular Disease	736
1. Tumors	737
a. Cystic Hygroma	737
b. Neck Teratoma	737
c. Cherubism	737
2. Congenital Hypoplasia	737
a. Acrocephalosyndactyly	737
i. Apert’s Syndrome.	738
6 Postintubation Procedures	955
47 Endotracheal Tube and Respiratory Care	957
I. Introduction	957
II. Properties of the Endotracheal Tube	958
A. Anatomy of the Endotracheal Tube	958
B. Development and Properties of the Endotracheal Tube	959
C. Physiologic Effects of Endotracheal Tube Placement	959
D. Complications of Endotracheal Tube Placement	960
III. Endotracheal Tubes and Other Airway Adjuncts	960
A. Choice of Endotracheal Tube Size	960
1. Small Tubes and Airway Resistance	960
2. Large Tubes and Trauma	961
B. Potentially Beneficial Alternatives to the Standard Endotracheal Tube	961
1. Preformed and Reinforced Tubes	961
2. Laser Tubes	962
3. Subglottic Suctioning Evac Endotracheal Tubes	962
4. Double-Lumen Endotracheal Tubes	963
5. Supraglottic Airways	963
IV. Proper Safeguarding of the Airway	964
A. Airway Evaluation: Predicting the Difficult Airway	964
B. Identifying Proper Position of the Endotracheal Tube	964
1. Detection of Esophageal Intubation	964
2. Confirmation of Appropriate Depth of Insertion	966
3. Cuff Pressure Monitoring	966
4. Evaluation of an Audible Cuff Leak	967
5. Documentation of Placement	967
C. Stabilization of the Endotracheal Tube	968
1. Taping	968
2. Commercially Available Devices	968
3. Stapling for Facial Burns	968
D. Rapid Response Cart for Airway Emergencies	971
V. Maintenance of the Endotracheal Tube	971
A. Heat and Humidity of Inspired Gas	971
B. Suctioning	973
C. Subglottic Care	974
D. Bronchoscopy	974
E. Biofilm Management	974
VI. Respiratory Therapies for the Intubated Patient	975
A. Secretion Clearance and Control Therapies	975
1. Mucolytic Agents	975
2. Chest Physiotherapy	976
a. Percussion and Postural Drainage	976
b. Positive End-Expiratory Pressure Therapy	976
c. Intrapulmonary Percussive Ventilation	976
d. High-Frequency Chest Wall Compression	976
B. Overcoming Work of Breathing Imposed by Endotracheal Tubes, Tracheostomy Tubes, and Ventilator Circuits	976
1. Pressure Support	976
2. Continuous Positive Airway Pressure	977
3. Automatic Tube Compensation	977
C. Pharmacologic Treatments	977
1. Inhalation Drug Delivery	977
a. Nebulizers	978
b. Metered-Dose Inhalers	978
2. Inhaled Bronchodilators	978
3. Anticholinergics	978
4. Corticosteroids	978
5. Inhaled Antibiotics	979
D. Positioning of the Patient	979
VII. Conclusions	979
VIII. Clinical Pearls	980
Selected References	980
References	980.e1
48 Mechanical Ventilation	981
I. Introduction	981
II. Initiation of Mechanical Ventilation	982
A. Tidal Volume	982
B. Respiratory Rate	982
C. Positive End-Expiratory Pressure	982
D. Fraction of Inspired Oxygen	983
E. Peak Pressure	984
F. Plateau Pressure	984
G. Trigger Sensitivity	984
H. Flow Rate	984
I. Flow Pattern	984
III. Common Modes of Mechanical Ventilation	984
A. Assist-Control Ventilation	985
B. Synchronized Intermittent Mandatory Ventilation	986
C. Pressure-Support Ventilation	989
D. Pressure-Regulated Volume Control	989
IV. Uncommon Modes of Ventilation	989
A. Inverse-Ratio Ventilation	989
B. Airway Pressure–Release Ventilation	989
C. High-Frequency Ventilation	989
V. Noninvasive Ventilation	991
VI. Weaning From Mechanical Ventilation	992
VII. Complications of Mechanical Ventilation	993
A. Mechanical Complications	993
1. Auto-PEEP	994
2. Consequences of Auto-PEEP	994
B. Infectious Complications	996
VIII. Conclusions	996
IX. Clinical Pearls	996
Selected References	997
References	997.e1
49 Monitoring the Airway and Pulmonary Function	998
I. Introduction	998
II. Monitoring the Airway	999
A. Non-intubated Patient	999
B. During Endotracheal Intubation	999
C. During Weaning	1001
D. After Tracheal Decannulation	1002
III. Monitoring Respiratory Function	1002
A. Clinical Assessment	1002
B. Radiologic Evaluation	1003
C. Assessment of Gas Exchange	1004
1. Blood Gas Monitoring	1004
2. Noninvasive Monitoring	1005
a. Pulse Oximetry	1005
b. Capnography	1011
IV. Monitoring Respiratory Function during Mechanical Ventilatory Support	1012
A. Assessment of Pulmonary Mechanical Function	1012
1. Airway Resistance and Lung-Thorax Compliance	1014
2. Intrinsic Positive End-Expiratory Pressure	1014
3. Ventilatory Waveform Analysis	1015
4. Work of Breathing	1016
B. Assessment of Pulmonary Function During Weaning	1016
1. Weaning Indices	1016
2. Breathing Pattern Analysis	1017
3. Airway Occlusion Pressure	1017
V. Conclusions	1017
VI. Clinical Pearls	1017
Selected References	1017
References	1017.e1
50 Extubation and Reintubation of the Difficult Airway	1018
I. Introduction	1019
II. Extubation Failures and Challenges	1019
III. Extubation Risk Stratification	1019
A. Routine Extubations	1020
1. Hypoventilation Syndromes	1020
2. Hypoxemic Respiratory Failure	1020
3. Inability to Protect the Airway	1020
4. Failure of Pulmonary Toilet	1021
5. Inadvertent Extubations	1021
6. Entrapment	1021
7. Hypertension and Tachycardia	1021
8. Intracranial Hypertension	1021
9. Intraocular Pressure	1021
10. Coughing	1021
11. Laryngeal Edema	1022
12. Laryngospasm	1022
13. Macroglossia	1023
14. Laryngeal or Tracheal Injury	1023
15. Airway Injury	1024
16. Postobstructive Pulmonary Edema	1025
B. Higher-Risk Extubations	1025
IV. Clinical Settings of Complications	1025
A. Operative Conditions	1025
1. Laryngoscopic Surgery	1025
2. Thyroid Surgery	1026
3. Carotid Artery Surgery	1027
4. Cervical Surgery	1028
5. Maxillofacial Surgery and Trauma	1029
6. Deep Neck Infections	1029
7. Posterior Fossa Surgery	1030
8. Stereotactic Surgery and Cervical Immobilization	1030
9. Tracheal Resections	1030
10. Palatoplasty	1030
B. Preexisting Medical Conditions	1031
1. Paradoxical Vocal Cord Motion	1031
2. Parkinson’s Disease	1032
3. Rheumatoid Arthritis	1033
4. Tracheomalacia	1033
5. Obstructive Sleep Apnea Syndrome	1034
6. Laryngeal Incompetence	1034
7. Pulmonary Aspiration of Gastric Contents	1034
V. Factors Affecting Intubation and Extubation	1035
A. Previously Encountered Airway Difficulties	1035
B. Limited Access	1035
C. High-Risk Cases	1035
VI. Extubation Strategies	1035
A. Deep versus Awake Extubation	1036
B. Extubation with a Laryngeal Mask or Other Supraglottic Airway	1036
C. Extubation or Reintubation over a Fiberoptic Bronchoscope or Laryngoscope	1037
D. Extubation with a Supraglottic Airway with or Without a Bronchoscope	1037
E. Use of a Gum Elastic Bougie or Mizus Endotracheal Tube Replacement Obturator	1037
F. Use of Jet Stylets	1038
G. Use of Commercial Tube Exchangers	1038
1. Tracheal Tube Exchangers	1039
2. Cook Airway Exchange Catheters	1039
3. Arndt Airway Exchange Catheter	1040
4. Endotracheal Ventilation Catheter	1041
H. Exchange of Double-Lumen Tubes	1041
1. Visually Assisted Tube Exchange	1042
2. Conversion from Nasal to Oral Intubation	1042
3. Conversion from Oral to Nasal Intubation	1042
4. Conversion from Supraglottic Airways to Endotracheal Tubes	1043
5. Changing Tracheostomy Tubes	1043
VII. Jet Ventilation Through Stylets	1043
A. In Vitro Studies	1043
B. In Vivo Studies	1044
VIII. Conclusions	1045
IX. Clinical Pearls	1045
Selected References	1046
References	1046.e1
51 Complications of Managing the Airway	1047
I. Complications in Managing Patients with Difficult Airways	1047
A. History of the Patient and Examination	1048
B. Omission, Commission, and Communication	1049
C. Planning and Scheduling	1049
II. Complications with Supralaryngeal Airway Devices	1049
A. Mask Ventilation	1049
1. The Sterilization Process	1049
2. Mechanical Difficulties	1049
3. Prolonged Mask Ventilation	1050
B. Laryngeal Mask Airway	1050
C. Esophageal-Tracheal Combitube	1051
D. Other Supraglottic Airway Devices	1051
III. Complications with Intubation	1052
A. Endotracheal Intubation	1052
1. Anatomic Requirements	1052
2. Laryngoscope Modifications and Rigid Optical Instruments	1052
3. Difficult Intubation	1053
4. Nasotracheal Passage	1053
a. Cranial Intubation	1053
b. Nasal Injury	1054
c. Foreign Bodies	1054
5. Traumatic Intubation	1054
a. Lip Trauma	1055
b. Dental Trauma	1055
c. Tongue Injury	1055
d. Damage to the Uvula	1055
e. Pharyngeal Mucosal Damage	1055
f. Laryngeal Trauma and Damage to the Vocal Cords	1055
g. Tracheobronchial Trauma	1056
h. Barotrauma	1056
i. Nerve Injuries	1057
j. Spinal Cord and Vertebral Column Injury	1057
k. Eye Injuries	1057
l. Temporomandibular Joint Injuries	1057
m. Damage to the Nose	1058
6. Esophageal Intubation	1058
a. Endotracheal Tube Placement	1058
b. Esophageal Perforation and Retropharyngeal Abscess	1058
7. Bronchial Intubation	1058
a. Use of an Endotracheal Tube	1058
b. Use of A Double-Lumen Tube	1059
B. Maintenance of the Endotracheal Tube	1059
1. Airway Obstruction	1059
2. Disconnection and Dislodgment	1060
3. Circuit Leaks	1060
4. Laser Fires	1060
C. Special Techniques	1061
1. Fiberoptic Intubation	1061
2. Lighted Stylets	1061
3. Submandibular and Submental Approach for Tracheal Intubation	1061
Iv. Complications with Infraglottic Procedures	1061
A. Translaryngeal Airway	1062
1. Retrograde Wire Intubation	1062
2. Cricothyrotomy	1062
B. Transtracheal Airway	1062
1. Transtracheal Jet Ventilation	1062
2. Percutaneous Dilatational Tracheostomy	1063
3. Formal Tracheostomy	1063
V. Physiologic Responses	1063
A. Hemodynamic Changes	1063
B. Laryngospasm	1063
C. Bronchospasm	1064
D. Coughing and Bucking	1065
E. Vomiting, Regurgitation, and Aspiration	1065
F. Intraocular Pressure Changes	1065
G. Intracranial Pressure Changes	1065
H. Apnea	1065
I. Latex Allergy	1065
VI. Complications with Extubation	1066
A. Hemodynamic Changes	1066
B. Laryngospasm	1066
C. Laryngeal Edema	1067
D. Laryngotracheal Trauma	1067
E. Bronchospasm	1067
F. Negative-Pressure Pulmonary Edema	1067
G. Aspiration	1067
H. Airway Compression	1067
I. Difficult Extubation	1068
J. Accidental Extubation	1068
VII. Conclusions	1068
VIII. Clinical Pearls	1068
Selected References	1069
References	1069.e1
7 Societal Considerations	1071
52 Teaching Airway Management Outside the Operating Room	1073
I. Background	1073
A. Is There Evidence That the Difficult Airway Guidelines Have Been Effective in Reducing Adverse Airway Events?	1073
II. Miller’s Learning Pyramid	1074
III. Computer-Based Learning	1074
IV. Efficacy of Simulation in Education	1075
V. Types of Simulators	1075
A. Low-Fidelity Simulators	1076
B. High-Fidelity Simulators	1076
VI. Airway Management Skills	1077
A. Bag-Mask Ventilation	1077
B. Pharyngeal Airways	1078
C. Supralaryngeal Airways	1078
D. Conventional Direct Laryngoscopy	1078
E. Video Laryngoscopy	1079
F. Fiberoptic-Assisted Endotracheal Intubation	1079
G. Invasive Airway Techniques	1080
H. Comprehensive Airway Management	1081
VII. Conclusions	1081
VIII. Clinical Pearls	1081
Selected References	1082
References	1082.e1
53 Airway Management Instruction in the Operating Room	1083
I. Introduction	1083
II. Importance of Lifelong Learning in Airway Management	1083
III. Teaching Airway Management—the Components	1085
IV. Instruction in Specific Techniques OR Devices	1085
A. Laryngeal Mask Airway	1085
B. Fiberoptic Intubation	1086
C. Surgical Airway	1088
V. Resident Training in Advanced Airway Management	1089
VI. Conclusions	1092
VII. Clinical Pearls	1092
Selected References	1093
References	1093.e1
54 Effective Dissemination of Critical Airway Information:	1094
I. Overview	1094
II. Difficult Airway/Intubation: a Multifaceted Problem	1095
A. Identification of Patients	1095
B. Multidisciplinary Practice Guidelines and Difficult Airway/Intubation Algorithms	1095
C. A Difficult Airway/Intubation Team	1095
D. Consequences of Difficult Airway Management	1096
III. Difficult Airway/ Intubation: Documentation of Critical Information	1096
A. Documentation in Medical Records	1096
B. Documentation in In-House Electronic Medical Records	1097
IV. Difficult Airway/ Intubation: Dissemination of Critical Information	1097
A. ASA Recommendations for Dissemination of Information	1097
B. Dissemination of Information via Paper Medical Records	1097
C. Verbal Dissemination of Information	1097
D. Dissemination of Information via Letters	1098
E. Dissemination of Information via Difficult Airway/Intubation Registries	1098
F. Dissemination of Information via Electronic Medical Records and Electronic Health Records Systems	1098
V. the Medicalert Foundation	1099
A. History of the MedicAlert Foundation	1099
B. Services Provided by the MedicAlert Foundation	1099
C. Membership in the MedicAlert Foundation	1100
VI. the Medicalert Foundation National Difficult Airway/Intubation Registry	1100
A. History of the Registry	1100
B. Objectives of the Registry	1101
C. Components of the Registry	1101
D. Characteristics of Registry Patients	1101
E. Benefits of the Registry	1101
VII. Other Emergency Medical Response Systems	1103
VIII. Conclusions	1103
IX. Clinical Pearls	1104
Selected References	1104
Appendix A	1105
References	1105.e1
Appendix B Anesthesia Advisory Council of the MedicAlert® Foundation	1105
Founding Members, 1992	1105
55 Medical-Legal Considerations:	1106
I. Historical Perspective	1106
II. the Closed Claims Perspective	1106
A. Principal Features of Adverse Respiratory Outcomes and High-Frequency Adverse Respiratory Events	1107
1. Basic Features	1107
2. Inadequate Ventilation	1108
3. Esophageal Intubation	1109
4. Difficult Intubation	1110
5. Aspiration	1110
B. Low-Frequency Adverse Respiratory Events	1111
1. Basic Features	1111
2. Airway Trauma	1111
3. Pneumothorax	1112
4. Airway Obstruction	1112
5. Bronchospasm	1112
C. Emerging Trends from the ASA Closed Claims Project	1113
III. Conclusions	1114
IV. Clinical Pearls	1114
Acknowledgments	1114
Selected References	1114
References	1114.e1
Index	1115
Numbers	1115
A	1115
B	1118
C	1119
D	1121
E	1122
F	1124
G	1125
H	1125
I	1126
J	1127
K	1127
L	1127
M	1129
N	1131
O	1132
P	1132
R	1135
S	1137
T	1138
U	1140
V	1140
W	1140
X	1141
Y	1141
Z	1141

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