AIRWAY DEVICES

Presenter- Dr.kaushal kumar

Moderator- Dr. Shashi prakash sir
 Airway Devices
Supraglottic Airway Devices
Lies above the laryngeal inlet
Infraglottic Airway Device
Lies below the laryngeal
inlet in the trachea
Supraglottic Airway Devices – Evolution
First generation devices- simple airway tubes
• Classic LMA
• Flexible LMA
• Cobra PLA
Second generation – includes drainage tubes
• LMA Supreme
• ProSeal LMA
• I-Gel
• LTS
Third generation - cuffless, two drain tubes, small bowl
• Baska mask.
 Based on sealing mechanism

Cuffed Peri-laryngeal Sealers

With esophageal sealing
Non directional non • Combitube,King LT LTS
esophageal sealers- Without esophageal sealing
cLMA, flexible LMA, COPA,pax
LMA unique Cuffless Pre-shaped Sealers
Directional nonesophageal With Esophageal Sealing
sealing- Baska Mask
LMA fastrach I-Gel
Directional esophageal Without Esophageal Sealing
sealing- SLIPA
Proseal LMA, LMA Supreme AirQ - SP

Cuffed Pharyngeal Sealers

CLASSIFICATION BASED ON THE NUMBER OF
LUMEN-
• Single Lumen Devices:- LMA-classic, LMA-unique, LMA-
flexible, ILMA, C-trach, Soft seal, Laryngeal Airway
Device(LAD), Ambu Laryngeal Mask, Pharyngeal airway
express(PAX), Cobra Perilaryngeal Airway(CPLA), Laryngeal
Tube(LT), Cuffed oropharyngeal airway, Stream Lined Liner
of the Pharyngeal Airway(SLIPA), Glottic Aperture Seal
Device.
• Double Lumen Devices:- Proseal LMA, Combitube,
Laryngeal Tube Suction(LTS), Airway Management
Device(AMD).
• Tripple Lumen Devices:- Elisha Airway Device(EAD)
 Why supraglottic devices
• Avoid tube –within- tube situation
• Lower hemodynamic instability
• Do not cause translocation of oral or nasal
bacterial colony and secretions into LRT.
• Bronchial intubation is totally avioded
• Ease of insertion and smooth awakening
• Some devices permit endotrachial intubation
if situation requires.
 Indications
• As a rescue airway devices during difficult
airway management
• Ambulatory surgery for ASA 1 and 2 patients
lasting for 2-3 hr
• Patients with coronary artery diseases coming
for short surgical procedure under GA
• Prior to termination of anaesthesia in
neurosurgery ET tube replaced with LMA and
in opthalmic surgeries to prevent sudden
increase IOP
• Primary airway devices when urgent airway
patency require in the lateral position
• Minor therapeutic or diagnostic procedure
outside the OT complex(radiation therapy,
diagnostic and interventional radiology,
endoscopy,ECT,cardioversion etc.)
 Contraindications
• Small oral aperture < 2cm
• Oropharyngal and hypopharyngeal mass
• Patients with possibility of reflux of gastric contents
may be present-
– When fasting can not be confirmed
– Gross or morbid obasity
– Pregnancy
– Multiple or massive injury
– Acute abdomen or thoracic injury
– Conditions associated with delayed gastric emptying
– history of hiatus hernia and GERD
• Patient with poor lung compliance or COPD as these
devices and can not withstand with high positive
inflation pressure without leak
Laryngeal Mask Airway (LMA)

• Classic LMA
• LMA unique
• LMA flexible
• LMA Supreme
• LMA Fastrach(Intubating LMA)
• ProSeal LMA
• Airway tube , mask,
inflation line
• Made up of medical grade
silicon and reused many
times after autoclaving
• Seal pressure 25 cm of
water
• Deflate cuff
• apply lubricant on posterior surface
• LMA tube be grasped like a pen with index
finger pressing the point where tube joins
mask.
• Neck flexed and head extended
• Use non-inserting hand to stabilize occiput
• Jaw should be pulled down by assistant.
• Press the tip of the LMA against the hard
palate to make mask flat and use the index
finger to guide the LMA,press beckword
toward the ear in one smooth movement
utill a definitive rsistance is felt.
• Before removing index finger brought non
dominant hand ,Grasp the tube firmly with
the non dominent hand and then withdraw
your index finger from the pharynx. Press
gently downward with non dominent hand
to ensure the mask is fully inserted.
• Inflate the cuff without holding it in place.
 SIGNS OF CORRECT PLACEMENT
• The slight outward movement of the tube upon LMA inflation.
• The presence of a smooth oval swelling in the neck around the thyroid
and cricoid area, or no cuff visible in oral cavity.
• Ventilate the patient while confirming equal breath sounds over both
lungs in all fields and the absence of ventilatory sounds over the
epigastrium.
Part of LMA Position
Distal tip of silicone cuff- Upper esophageal sphinter
Sides of the cuff- Pyriform fossa
Upper part of the cuff - Tounge base
LMA size Weight(kg) max Cuff ET tube(mm)
volume(ml)
1 5 4 3.5
1.5 5-10 7 4.0
2 10-20 10 4.5
2.5 20-30 14 5.0
3 30-50 20 6.0
4 50-70 30 6.0
5 70-100 40 7.0
6 >100 50 7.0
 Complications
• When lubricant has been liberally applied on
the LMA it may promote coughing and
laryngospam
• Folding the epiglottis tip between vocal cords
resulting coughing, laryngospam even airway
obstruction
• Regurgitation and aspiration
• Sore throat and transient dysarthria because
increase LMA cuff pressure beyond the
recommended 60 cm of water
• Failed LMA placement
• Oedema of epiglottis, uvula and posterior
pharyngeal wall
• Hypoglossal nerve paralysis,post obstructive
pulmonary oedema, tongue cynosis ,tension
pneumoperitonium and gastric puncture.
• Single use,PVC
made,cheaper
• Less rise Of intracuff
pressure with N2O
• More dificult to insert
• Same size as cLMA
• Flexometallic tube-
nerrower and longer
• Seal pressure 20 cm of
water
• more useful in Head and
neck surgeries,ENT and
upper torso procedure
where need to
reposition the airway is
prevalent.
• Problem-increase airway
resistence,limit
endoscope and ET tube
insertion,unsuitable for
MRI
 • Ambu aura once -Single use
Ambu aura laryngeak mask LM with preformed curve
• Ambu aura 40
resuable,silicon version of
ambu aura oncce
• Ambu aura i design to
facilitate intubation
• Three part-airway tube,
mount area ,bowl
• Mount and airway tube
bent at an angle 90 degree
follow the anatomy of
pharynx, hypopharynx to
aid its placement without
using index finger
• Fixation tab-visual guide to • Drainage tube- run
check correct size. After through the midline of
inflation FT should be 1.5 to the airway dividing it into
2 cm from the upper lip. if 2 narrow lumen. This
distance<1.5 then size too limits its use as conduit
small ,if >3 cm size too large for intubation and airway
• Airway tube- anatomically inspection
shaped( easy insertion), • Cuff-modified and
elliptical in cross section enlarged inflatable cuff,
( facilitate insertion in seal pressure between
patient with less interdental PLMA and cLMA(36.1 cm
space, decrease airway of water) ,moulded distal
resistance, minimize cuff prevent folding
accidental rotation)
• Anatomically curved
according to palate and
post pharyngeal wall
• An epiglottic elevator bar at
the mask aperture
• Armoured flexible ET tube
with a logitudinal and
horizontal black line.
• The stablizer road of 25 cm
• Seal pressure 60 cm of
water
Body weight(kg) ILMA size Air volume Tracheal tube
30-50 3 20 7mm
50-70 4 30 7.5mm
70-100 5 40 8mm
• Position: Neutral
• Apply water soluble lubricant posteriorly
• Hold rigid handle parallel to patient’s chest.
Flattened the tip against the palatal
sarface,drawing back slightly to ensure complete
flattening of the rim of mask.
• Rotate the rigid handle directing towards
patient’s nose following the arch of the palate
and posterior pharyngeal wall, till it can not be
advanced. Inflate the cuff without holding it in
place & check ventilation.
• Introduce FETT with black line facing rigid
handle till 15 cm mark.
• Now grip ILMA handle firmly and lift it forward
by few mms without levering. Advance the tube
using clinical judgment. Inflate the cuff and
check for tracheal intubation.
• After confirmation of tracheal intubation deflate
the ILMA cuff.
• Remove FETT connector ,Insert the stabilizing
rod(25 cm) in the FETT to keep it in place.
• Remove the ILMA gently over the stabilizing rod
until it is clear of the oral cavity.
• Stabilize the FETT to prevent accidental
extubation.
• Remove ILMA and the stabilizing rod.
• Reconnect FETT connector and the breathing
circuit and confirm position again
 CHANDY’S MANEUVER
They increases the seal pressure and aligns the axes of
trachea and FETT. This prevents the endotracheal tube
(ETT) from colliding with the arytenoids and facilitates the
smooth passage of the ETT into the trachea.
First step : Rotating ILMA in coronal & sagittal plane in an
attempt to find least resistant to bag ventilation position.
Second step : is to grasp the handle and use it to draw LMA
forward 2-5 mm in a lifting action without levering teeth
 Advantages
• to facilitate tracheal intubation
• Can also be use as a primary airway device
• Rescue device for failed intubation
• Blind or fiberoptic guided insertion in
presence of blood or clot in oral cavity
 Disadvantages
• Pharyngeal pathology or limited mouth
opening
• Can not be used in patient below 30 kg
• On removal of ILMA, tracheal tube may be
displaced downward or dislodged
• Unsuitable for use in MRI
• Increase incidence of sore throat and
swallowing difficulty
• Esophageal intubation
• Reusable silicon made
Modifications
• airway tube ,Oesophageal
drain tube
• Ventral and dorsal inflatable
cuff
• Reinforced airway tube
• Integral bite block
• introducer

• Higher leak pressure then

classical airway(35 cm of
water)
PLMA size Weight(kg) Gastric tube Cuff inflation ET tube
size(French) volume(ml)

1 <5 8 4 3.5

1.5 5-10 10 7 4.0

2 10-20 10 10 4.5

2.5 20-30 14 14 5.0

3 30-50 16 20 5.0

4 50-70 16 30 5.5

5 70-100 18 40 6.0
• Without introducer-identical to the
cLMA
• With Introducer: a metal introducer is
attached to the concave side of the
device,distal end of introducer is
placed in the location strap and
proximal end engaged between the
two tube above the bite block .It is
then introduced in the same manner
as an intubating LMA.once
placed ,introducer disengaged
proximally from between the two
tube and removed following the arc
of blade.
• Bougie-guided: a bougie is placed
upside down into the oesophagus
and the PLMA with well lubricated
drain tube inserted over the gum
elastic bougie.This technique had a
significantly higher success rate.
• Suprasternal notch test
• Gastric tube test
• Gastric leak test
 Classical v/s proseal LMA
Advantages
• Separate gastric tube for gastric access and
checking correct positioning
• Bougie guided insertion of ET tube
• Dorsal cuff provide better seal and higher
sealing pressure(35-38 cm 0f water)
• Lesser incidence of gastric aspiration
• Bite block
• Can be use in both spontaneous and
controlled ventilation
 Disadvantages
• More incidence of trauma
• Equivocal incidence of sore throat as
compared to cLMA
• Slightly longer insertion time as compared to
cLMA
• 20% more resistance then classic airway in
spontaneously breathing patient
• Less suitable for as intubation device
• Require a greater depth of anaesthesia for
insertion
• Esophageal Tracheal Airway”
• Blind insertion airway device (BIAD)
• Double lumen airway device designed for
emergency ventilation of a patient when
visualization of the airway and endotracheal
intubation are not possible
• Ventilation can be achieved with either
tracheal or esophageal placement of tube
 Combitube Advantages
• Blind insertion without the need for light,
laryngoscope, or direct visualization
• Effective ventilation and oxygenation with
moderate protection against aspiration
• Proximal pharyngeal balloon provides better air seal
• Gastric contents can be aspired through lumen #2
when the device is in the esophagus
 Combitube Disdvantages:
• Pediatric sizes not available
• Expensive
• Increased chance of laryngeal and tracheal
injury
• Latex hypersensitivity (the pharyngeal balloon
contains latex
 Combitube Contraindications
• The patient has intact gag-reflex
• The patient is less than 5 feet tall or under 16
years old
• History of ingestion of caustic substance
• Burns involving the airway
• History of esophageal disease
• History of latex hypersensitivity
• Made of medical grade thermoplastic
elastomer -Styrene Ethylene Butadiene
Styrene(SEBS)
• Soft gel like non inflatable cuff adapts to
patient airway and provide anatomical seal
without any cuff inflation
Igel size Weight(kg) NG tube ET tube
(french) size
1 2-5 -
1.5 5-12 10 3
2 10-25 12 4
2.5 25-35 12 5

3 30-60 12 6
4 50-90 12 7
5 >90 14 8
 advantages
• Better anatomically fit –less compression trauma
• Less risk of injuries related to cuff hyperinflation
• Easy insertion reduses the time for successful
insertion
• Greater airway seal
• Wide luman allow for airway rescue and assisted
intubation
• Effective in prone position ventilation
 ELISHA airway devices(EAD)
• Silicone made latex free
• Three separate channel for ventilation, Intubation ( Allowed
8.0 ETT blind or fiberoptic insertion)and gastric tube
insertion.3 function in single device without interruption to
each other.
• 2cuff proximal for pharynx
and distal for esophagus.

• VC and IC side by side join at

the ventilation outlet and
gastric tube outlet at the distal
end of the device.
 Cuffed oropharyngeal airway(COPA)
• PVC made single use
• Distal cuff inflate below
the soft palate behind
the tongue,above the
epiglottis and with in
the oropharynx.
• Insertion like gudel’s
oropharyngeal airway
• Used in spontaneously
breathing patient with
no risk factor of
aspiration
 Baska mask v/s LMA
• Smaller bowl compaired to other LMA so less
risk of including oesophageal opening
• Ajustable tab in shaft
• Double gastric channel-less chance of
oesophageal wall
impinging the gastric
opening during suction.
 Classification
• Murphy-type tube
• Magill type tube
• Spiral embedded (flexometallic) tube
• Special tube(preformed tubes, laser resistant
tubes,double lumen tube etc.)
 Requirements of an Ideal ETTube
• Smoothness of outer surface to avoid damage to mucosa
• Smooth & non-wettable inner surface.
• Non-inflammable
• Transparent
• Easily sterilizable
• Non-kinking
• Sufficiently strong - to allow thin wall framework
• Thermoplasticity - to conform to anatomic passage and to be self
centering within the trachea.
• Non reactive with lubricants or anesthetic agents
• Latex free
• Non injurious catheter tip
 ET Tube Cuff
• The cuff is an inflatable sleeve near the patient end of ETT.
• The cuff material should be strong and tear resistant but
thin, soft and pliable.
• Cuffs are usually made of the same material as the ETT.
• Provides a seal between tube & tracheal wall to prevent
aspiration of gastric contents
• Prevents air-leak
• Serves to center the tube in trachea
• Can be high volume - low pressure system or low volume -
high pressure system
• Normal recommended cuff pressure -20-30 cm H2o
• Damage to tracheal mucosa - >30 cm H2O
• Total obstruction of tracheal blood flow - >50 cm H2O
• Usually 10 ml of air is sufficient for adequate cuff pressure 20 – 30 cm
H2O
 Factors Affacting Cuff Pressure
Increase cuff pressure Decrease cuff pressure
• Positive pressure ventilation • Sedation
• Ventilation with N2O • Neuromuscular blockade
• Bronchoconstriction • Reduced core temperature
• Laryngeal spasm • Time
• Edema • Changes in body position
 RAE (Ring, Adair and Elwyn) ETT
• Made of plastic and come in both plain and cuffed
version.
• Preformed north facing nasotracheal (RAE
nasal) ,preformed south facing orotracheal tube(RAE
oral).
• Advantage- easy to secure and allow the breathing
circuit to be away from the surgical field
• Disadvantage-increase in resistance to breathing,
difficulty in suctioning, inability to fit in all patients
because of their fixed lengths.
 Flexomettalic ETT(armored,anode,spiral
embedded or reiforced)
• Metal or nylon wire running between inner and
outer layer of PVC, nylon or silicone.
• Require stylet for aapropriate curvature
Use- cleft lip and palate,head and neck surgery,
neurosurgical procedure.
Disadvantage-inability to be shortened, absence of
murphy’s eye in some of the tube, difficult
nasotrachial intubation, occasional saperation of the
two layer( especially after autoclaving)
 Laser flex tube
• Stainless steel tube with smooth plastic surface
• Surface of the tube can reflect a laser beam
• Use with CO2 and KTP lasers
• 2 cuff proximal and dista, filled with isotonic
saline,advantage is that distal cuff can be use if
the proximal one isdamaged by laser
• Murphy eye as an added distal opening
 Double lumen tube

• Older-Robertshaw DLT, made up of red

rubber ,reusable,not used now
• Newer varient-Bronchocath DLT, PVC, disposable
• Blue colour coaded bronchial cuff, proximal lumen,pilot
baloon
• transparent trachial lumen
• X ray opaque markers at distal tip,above the bronchial
cuff,at the trachial opening
Use- selective deflation of one lung while maintaining
ventilation of the other lung
• Microlaryngeal tube
• Endotrachial tracheal tube
• Laryngectomy tracheal tube
• Oxford preformed trachial tube
Ideal Suction Catheter Size Ideal Suction Pressures

• Measured in French • Adult – -100 to -120 mmHg

(French/3.14 = size in mm) • Child – -80 to -100 mmHg
• Diameter of catheter < ½ • Infant – -60 to -80 mmHg
inner diameter of tube
• Size 10 ETT 14 Fr
• Size 8 ETT 12 Fr
• Size 6 ETT 10 Fr
• Infants 6 - 8 Fr
• 2 – 6 years 10 Fr
• 7 – 15 years 12 Fr
• >16 years 12 - 14 Fr
 Hazards of Suctioning
• Trauma
• Hypoxia – Arrhythmias
• Cerebral hypoxia
• Vagal Stimulation
• Atelectasis
• Infection
• Bronchospasm
• Raised ICP
• Stimulation of gag Reflex
 Uses –
• To maintain open airway
• Prevent endotracheal tube occlusion
• Prevent tongue bite
• Facilitate suction
• Conduit for passing devices into oropharynx
• Obtain a better mask fit
Contraindications
• Intact gag reflex
• Oropharyngeal growth
THANK YOU