Atlas of Airway Management: Techniques and Tools

433 Pages·2011·42.93 MB·English

by  Steven L. Orebaugh MD

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Atlas of
Airway Management:
Techniques and Tools
2nd Edition
Steven L. Orebaugh, MD
Associate Professor of Anesthesiology and Critical Care Medicine
University of Pittsburgh School of Medicine
UPMC Southside/Mercy Amulatory Center
Pittsburgh, Pennsylvania
Paul E. Bigeleisen, MD
Professor of Anesthesiology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

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Library of Congress Cataloging-in-Publication Data
Orebaugh, Steven L.
Atlas of airway management : techniques and tools / Steven L. Orebaugh. — 2nd ed.
p. cm.
ISBN 978-1-4511-0339-7
ISBN 1-4511-0339-5
1. Airway (Medicine)—Atlases. 2. Trachea—Intubation—Atlases. 3. Artificial respiration—Atlases. I. Title.
RC732.O74 2012
616.2'3—dc23
2011022795
First Edition ©2007 by Lippincott Williams & Wilkins
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However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from
application of the information in this book and make no warranty, expressed or implied, with respect to the currency,
completeness, or accuracy of the contents of the publication. Application of the information in a particular situation
remains the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in
this text are in accordance with current recommendations and practice at the time of publication. However, in view of
ongoing r esearch, changes in government regulations, and the constant flow of information relating to drug therapy and
drug r eactions, the reader is urged to check the package insert for each drug for any change in indications and d osage
and for added warnings and precautions. This is particularly important when the recommended agent is a
new or i nfrequently e mployed drug.
Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status
of each drug or device planned for use in their clinical practice.
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Dedication ccnn
We dedicate this atlas to the anesthesiology residents, anesthesiologists and other
acute care p hysicians who provide life-saving airway management to the patients
at the University of Pittsburgh Medical Center hospitals.

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Contributors List
Ali R Abdullah, MBChB Franklyn Cladis MD
Resident Physician, Department of Anesthesiology, Assistant Professor, Department of Anesthesiology, The
University of Pittsburgh School of Medicine, Pittsburgh, University of Pittsburgh School of Medicine, Children’s
Pennsylvania Hospital of Pittsburgh of UPMC, Pittsburgh Pennsylvania
Mark Backeris, DO Ivan Colaizzi, MD
Resident Physician, Department of Anesthesiology, Clinical Assistant Professor, Department of Anesthesiology,
University of Pittsburgh School of Medicine, Pittsburgh, Univeristy of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania Pennsylvania
Joshua Baisden, MD Christopher W. Connor, MD, PhD
Department of Anesthesiology, University of Pittsburgh Assistant Professor of Anesthesiology and Biomedical
Medical Center, Pittsburgh, Pennsylvania Engineering, Boston University, Boston, Massachusetts
Ryan D. Ball, MD Daniel Cormican, MD
Chief Anesthesiology Resident, Department of Resident Physician, Department of Anesthesiology,
Anesthesiology, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh,
Pittsburgh, Pennsylvania Pennsylvania
Shawn T. Beaman, MD David Crippen, MD, FCCM
Assistant Professor, Associate Residency Program Director, Professor, Department of Critical Care Medicine, University
Department of Anesthesiology, University of Pittsburgh of Pittsburgh Medical Center, Pittsburgh, PA
School of Medicine, Pittsburgh, Pennsylvania
Patricia Dalby, MD
Nikhil Bhatnagar MD Assistant Professor, Department of Anesthesiology,
Resident Physician, Department of Anesthesiology, University of Pittsburgh School of Medicine,
University of Pittsburgh Medical Center, Pittsburgh, Anesthesiologist, Department of Anesthesiology,
Pennsylvania Magee-Women’s Hospital, Pittsburgh, Pennsylvania
Brian Blasiole, MD, PhD James Dargin, MD
Fellow, Pediatric Anesthesiology, Department of Intensivist, Department of Pulmonary and Critical Care
Anesthesiology, University of Pittsburgh Medical Center, Medicine, Lahey Clinic, Burlington, Massachusetts
Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
Derek Davis, MD
Lawrence M. Borland, MD Assistant Professor, Department of Anesthesiology,
Associate Professor, Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Pennsylvania
William B. Ehrman, DO
Adam P. Childers, MD Resident Physician, Department of Anesthesiology,
Resident, Department of Anesthesiology, University of University of Pittsburgh Medical Center, Pittsburgh,
Pittsburgh Medical Center, Pittsburgh, Pennsylvania Pennsylvania
iv

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CONTRIBUTORS LIST v
Lillian L. Emlet, MD, MS, FACEP Arun L. Jayaraman, MD, PhD
Assistant Professor, Department of Critical Care Medicine Resident Physician, Department of Anesthesiology,
and Emergency Medicine, University of Pittsburgh Medical University of Pittsburgh School of Medicine, Pittsburgh,
Center, Pittsburgh, PA Pennsylvania
CA-2 Resident, Department of Anesthesiology, University of
Stephen Esper, MD Pittsburgh Medical Center
Resident, Department of Anesthesiology, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania A. Murat Kaynar, MD, MPH
Attending Physician, (Assistant Professor), Department of
Peter F. Ferson, MD Critical Care Medicine and Department of Anesthesiology,
Professor of Surgery, Department of Cardiothoracic University of Pittsburgh School of Medicine, Pittsburgh,
Surgery, University of Pittsburgh School of Medicine, Pennsylvania
Staff Surgeon UPMC Presbyterian and VA Health System,
Pittsburgh Miroslav Klain, MD, PhD
Professor Emeritus, Department of Anesthesiology,
Patrick Forte, MD University of Pittsburgh Medical School, Attending
Assistant Professor, Department of Anesthesiology, University Physician, Department of Anesthesiology, Presbyterian
of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania University Hospital, Pittsburgh, Pennsylvania
Theresa Gelzinis, MD Tara Knizner, MD
Assistant Professor, Associate Professor of Anesthesiology, Resident, Department of Anesthesiology,
University of Pittsburgh School of Medicine, Pittsburgh, PA University of Pittsburgh Medical Center, Pittsburgh,
Staff Anesthesiologist, University of Pittsburgh Medical Pennsylvania
Center-Oakland
Robert Scott Lang, MD
Brian Gierl, MD Resident, Department of Anesthesiology,
Resident Physician, Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Pennsylvania
Kristin Ondecko Ligda, MD
Joseph S. Goode, Jr., CRNA, MSN Resident Physician, Department of Anesthesiology,
Faculty, University of Pittsburgh School of Nursing, Nurse University of Pittsburgh, Pittsburgh, Pennsylvania
Anesthesia Program Staff Nurse Anesthetist
UPMC-Presbyterian, Pittsburgh, PA Charles Lin, MD
Attending Anesthesiologist, Department of Anesthesiology,
Kevin M. Hibbard, MD University of Pittsburgh Medical Center, Pittsburgh,
Resident, Department of Anesthesiology, University of Pennsylvania
Pittsburgh, University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania Mark I. Lischner, DO
Resident, Department of Anesthesiology, University of
Ibtesam Hilmi, MB CHB, FRCA Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Associate Professor, Department of Anesthesiology,
Associate Professor, Clinical and Translational Science Matthew JP LoDico, MD
Institute, University of Pittsburgh, Director of Quality Resident Physician, Department of Anesthesiology,
Assurance UPMC-Presbyterian Hospital University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania
Bo Hu, PhD
Department of Anesthesiology, University of Rochester Michael Mangione MD
School of Medicine and Dentistry and Center for Visual Associate Professor of Anesthesiology, University of
Science, University of Rochester, Rochester, New York Pittsburgh School of Medicine, Chief of Anesthesiology, VA
Pittsburgh Healthcare System
Dustin J. Jackson, MD
Resident, Department of Anesthesiology, Unviersity of Ana Manrique, MD
Pittsburgh School of Medicine, University of Pittsburgh Resident, Department of Anesthesiology, University of
Medical Center, Pittsburgh, Pennsylvania Pittsburgh Medical Center, Pittsburgh, Pennsylvania

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vi CONTRIBUTORS LIST
Stephen M. McHugh, MD Katherin A. Peperzak, MD
Resident, Department of Anesthesiology, University of Resident, Department of Anesthesiology, University of
Pittsburgh Medical Center, University of Pittsburgh Medical Pittsburgh Medical Center, Pittsburgh,
Center, Pittsburgh, Pennsylvania Pennsylvania
William R. McIvor, MD
Paul E. Phrampus, MD
Associate Professor, Department of Anesthesiology,
Associate Professor, Departments of Emergency Medicine
University of Pittsburgh School of Medicine, Pittsburgh,
and Anesthesiology, Vice Chair, Quality and Patient Safety,
Pennsylvania
Department of Emergency Medicine, Director, Peter M
Winter Institute for Simulation, Education and Research
Samer Melhem, MD
(WISER), University of Pittsburgh and UPMC, Pittsburgh,
Resident Physician, Department of Anesthesiology,
Pennsylvania
University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania
Raymond M. Planinsic, MD
Associate Professor of Anesthesiology, University of
David G. Metro, MD
Pittsburgh School of Medicine, Director of Transplantation
Assistant Professor, Associate Professor of Anesthesiology,
Anesthesiology, University of Pittsburgh Medical Center,
University of Pittsburgh School of Medicine, Pittsburgh, PA
Pittsburgh, Pennsylvania
Staff Anesthesiologist, University of Pittsburgh Medical
Center-Oakland
Joseph J. Quinlan, MD
Mario Montoya, MD Professor of Anesthesiology, Department of Anesthesiology,
Visiting Assistant Professor, Department of Anesthesiology, University of Pittsburgh, Chief Anesthesiologist, Department
University of Pittsburgh Medical Center, Pittsburgh, of Anesthesiology, University of Pittsburgh Medical
Pennsylvania Center - Presbyterian, Pittsburgh, Pennsylvania
Scott K. Muir, DO
Max E. Rohrbaugh, MD
Resident Physician, Department of Anesthesiology,
Resident, Department of Anesthesiology, University of
University of Pittsburgh, University of Pittsburgh Medical
Pittsburgh, Pittsburgh, Pennsylvania
Center, Pittsburgh, Pennsylvania
Ryan C. Romeo, MD
Adam Munson-Young, MD
Associate Professor of Anesthesiology, University of
Resident, Department of Anesthesiology, University of
Pittsburgh School of Medicine, Pittsburgh, PA
Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Andrew Murray MB ChB Tetsuro Sakai, MD, PhD
Assistant Professor, Department of Anesthesiology, Associate Professor, Department of Anesthesiology,
University of Pittsburgh School of Medicine, Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania Pennsylvania; Faculty Member, The McGowan Institute for
Regenerative Medicine, University of Pittsburgh, Pittsburgh,
Spencer G. Nabors, MD, MPH, MA Pennsylvania
Postdoctoral Scholar, Clinical Instructor, Department of Critical
Care Medicine, University of Pittsburgh Medical Center
Kristin Schreiber, MD/PhD
Resident Physician, Department of Anesthesiology,
Todd Oravitz, MD
University of Pittsburgh School of Medicine, Pittsburgh,
Associate Professor, Department of Anesthesiology,
Pennsylvania
University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania
Scott Segal, MD, MHCM
Professor and Chair, Department of Anesthesiology, Tufts
Sarah Parker, MD
University School of Medicine, Boston, Massachusetts
Resident, University of Pittsburgh School of Medicine,
Department of Emergency Medicine
Pranav R. Shah, MD
Nimitt J. Patel, MD Resident Physician, Department of Anesthesiology,
Fellow, Surgical Critical Care, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh,
University of Pittsburgh, Pittsburgh, Pennsylvania Pennsylvania

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CONTRIBUTORS LIST vii
Anthony Silipo, DO PGY-4 Samuel A. Tisherman, MD
Chief Resident Physician, Department of Anesthesiology, Professor, Departments of Critical Care Medicine and
University of Pittsburgh School of Medicine, Pittsburgh, Surgery, University of Pittsburgh, Pittsburgh, PA
Pennsylvania
Jay B. Tuchman MD, FAAP
Elizabeth H. Sinz, MD Assistant Professor, Department of Anesthesiology,
Professor, Department of Anesthesiology & Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh,
Director, Penn State Hershey Clinical Simulation Center, Pennsylvania
Office of Education Affairs, Penn State Hershey Medical
Center, Hershey, Pennsylvania Manuel C. Vallejo, MD, DMD
Professor, Department of Anesthesiology, University of
Pittsburgh, Director, Obstetric Anesthesia, Department
James V. Snyder, MD
of Anesthesiology, Magee-Womens Hospital of UPMC,
Professor Emeritus, Critical Care Medicine, University of
Pittsburgh, Pennsylvania
Pittsburgh Medical Center
Audra Webber, MD
Erin A. Sullivan, MD
Resident Physician, Department of Anesthesiology,
Associate Professor of Anesthesiology, Director Division
University of Pittsburgh School of Medicine, Pittsburgh,
of Cardiothoracic Anesthesiology, University of Pittsburgh
Pennsylvania
Physicians Department of Anesthesiology, Pittsburgh,
Pennsylvania
Cynthia Wells, MD
Assistant Professor of Anaesthesiology, University
Kathirvel Subramaniam, MD
of Pittsburgh School of Medicine, Department of
Clinical Assistant Professor, Department of Anesthesiology,
Anesthesiology, Staff Anesthesiologist UPMC-Presbyterian,
University of Pittsburgh School of Medicine, Pittsburgh,
Pittsburgh, PA
Pennsylvania
Ryan R. Wilson, MD
Joseph F. Talarico, DO Resident Physician, Department of Anesthesiology,
Associate Professor of Anesthesiology, University of University of Pittsburgh School of Medicine, Pittsburgh,
Pittsburgh School of Medicine, Pittsburgh, PA Pennsylvania Ryan R. Wilson, MD PGY-3 Department of
Anesthesiology University of Pittsburgh Medical Center
Paul G. Tarasi, MD
Resident Physician, Department of Anesthesiology, Jacek Wojtczak, MD, PhD
University of Pittsburgh School of Medicine, Department of Anesthesiology, University of Rochester
University of Pittsburgh Medical Center, Pittsburgh, School of Medicine and Dentistry and Center for Visual
Pennsylvania Science, University of Rochester, Rochester, New York

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Preface to the Second Edition
I
n this, the second edition of the atlas, a number of situations, diagnostic and therapeutic bronchoscopy, and
changes will be evident. Most importantly, each chapter management issues for the post-intubation phase of care.
is now written by a separate set of authors, rather than In order to broaden the appeal of the book for non-
the entire book resulting from the efforts of one individ- anesthesia providers, and in recognition of the frequency
ual, in order to take advantage of the variable experiences of emergent airway management outside of the operat-
and expertise of many different practitioners. In addition ing room, the authors of the chapters are comprised of
to updates and revisions of existing chapters, many new a diverse group of practitioners, including anesthesiolo-
chapters have been added to improve the scope and per- gists (adult and pediatric), intensivists, emergency medi-
spective of the atlas, while describing innovative new tools cine physicians and trauma surgeons. One section of the
which have been added to the clinician’s armamentarium. book includes chapters from critical care physicians and
Examples of specific implements that are now dis- emergency medicine practitioners, describing the unique
cussed in this edition include the Airtraq (chapter 16), a and challenging aspects of airway management that such
prism- and mirror-based device to improve visualization physicians routinely face in the non-operating room
of the larynx, and the video-laryngoscopes recently re- environment.
leased by several manufacturers, which have been rapidly Finally, it must be recognized that direct laryngos-
and successfully adopted to cope with difficult anatomic copy remains the first management choice for acute care
characteristics (chapter 24). Several chapters are now physicians in most situations, for patients requiring intra-
included which describe unique and thought-provoking operative care or emergent airway interventions for other
methods for evaluating a patient’s physical characteristics reasons. Accordingly, the chapters from the prior edition
to help predict the likelihood of difficult laryngoscopy and which deal with airway anatomy, direct laryngoscopy and
intubation. In addition, a chapter has been added to de- the teaching of laryngoscopy to trainees, have been ex-
scribe the nature and utility of non-invasive ventilation, panded in scope, and re-focused in order to provide better
which may reduce morbidity in certain categories of pa- background and instruction for more challenging cases.
tients suffering from respiratory compromise (chapter 3). These now contain suggestions for improved patient po-
High frequency jet ventilation, a modality which may be sitioning, use of assistants to help lift the head and avoid
of use in a number of different operative and critical care operator fatigue, and external manipulation of the larynx
settings, is now considered as well (chapter 48). in a “two-handed” laryngoscopy technique, all of which
Entire new sections have been added to this book, aid in reducing the difficulty of exposing the glottis and
in order to provide coverage of topics which were not effectively placing the endotracheal tube in the airway.
considered, or which were described only briefly, in the
first edition. These include pediatric airway manage- The editors:
ment, preexisting pathology in patients which requires Steven L. Orebaugh
special attention to airway management, specific surgical Paul E. Bigeleisen
viii

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Preface to the First Edition ccnn
M
y aim in creating this book is to assist those learning ventilation, direct laryngoscopy, and pharmacology rel-
to manage the airway to understand the basics— evant to endotracheal intubation. While the purpose of
mask ventilation and optimal direct laryngoscopy—as this book is to provide information on management of the
well as to comprehend alternative techniques for situ- adult airway, a chapter on the pediatric airway is i ncluded.
ations in which direct laryngoscopy is difficult, or can- When applicable, references to pediatric airway manage-
not be utilized. There is an ever-expanding array of air- ment are made in the various chapters covering imple-
way tools, of many different types, covering a spectrum ments or techniques. In the second section, difficult airway
of costs and degrees of complexity. It behooves the pro- management is explored, including the epidemiology of
vider to u nderstand how different techniques work and this life-threatening problem in elective cases in operating
when they are effective so that two or three alternatives room, and in more emergent settings. Decision-making in
to laryngoscopy can be chosen, learned, and practiced. the face of recognized or potential difficult airways, due
Because I initially trained in emergency medicine, then to anatomy, disease, or obesity, for example, is discussed,
critical care medicine and, finally, anesthesiology, I have as well as training of physicians, students, and nurses at
experienced airway management from several different the University of Pittsburgh utilizing high fidelity human
viewpoints. I have attempted to share these perspectives simulation. In the last chapter of this section, a survey of
in this atlas. anatomic and pathologic causes of difficult a irway man-
Many fine airway management books exist, rang- agement is presented.
ing from small handbooks to expansive texts. Some of Brevity and an organized format for the text are as im-
these texts suffer from a lack of instructive illustration. portant in an atlas as are the illustrations themselves. For
In an attempt to complement them, this atlas was created, this reason, the chapters covering specific tools or tech-
and thus provides more illustration than text. In order niques are arranged according to the following template:
to make the relationships between anatomy and airway The concept is presented, followed by a discussion of
management tools clear, a large variety of illustrations is existing evidence supporting the use of the intervention.
presented, including mockups in cadaver specimens, pho- Next, the preparatory steps for the procedure are listed,
tos of airway management in the clinical setting, simu- followed by a description of the steps necessary to carry
lated airway management scenarios, and photographs of out the procedure itself. Following this is a listing of ele-
the  airway utilizing video laryngoscopes and fiberoptic ments of practicality, affordability, portability, familiarity,
bronchoscopes. complexity, and other concerns which impact the ability
Most of the atlas is dedicated to defining and illustrat- to integrate the tool or technique into medical practice.
ing the many devices and techniques that exist for endo- Finally, indications, contraindications, and complications
tracheal intubation when direct laryngoscopy is difficult of the intervention are noted. A series of illustrations is
or undesirable. These topics are covered in eight parts, in provided, showing the tool(s) involved, how these are
the following areas: adjuncts to direct laryngoscopy, blind placed in the patient (demonstrated in a cadaver speci-
intubation techniques, light-guided intubation, retrograde men), and clinical photos, or simulations, of the device
intubation, fiberoptic techniques, emergency ventilation in use. When appropriate, step-by-step sequential illustra-
techniques (supraglottic and infraglottic), combinations tions show the progression of the procedure.
of techniques, and emergency surgical airways. Within
each section are one to five chapters detailing the devices Steven L. Orebaugh, MD
or procedures that fall under that heading. Assistant Professor of Anesthesiology
The first portion of this atlas is intended to cover basic Assistant Clinical Professor of Emergency Medicine
airway management, including airway anatomy, b ag-mask University of Pittsburgh Medical Center, Southside
ix

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