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INTRODUCTION

Management of the upper airway, in both acute and elective settings, requires significant expertise, proper equipment, and organizational structure. Airway management is generally an interprofessional and interdisciplinary team effort that is enhanced by coordination and planning. Complications from a difficult intubation or problems from tracheostomy create may lead to considerable morbidity and mortality. Closed-claims analysis of medicolegal cases in anesthesiology reveals that litigation for patient harm related to airway management is generally associated with severe morbidity related to intubation and tracheostomy.1,2 Multidisciplinary management of the airway, operator preparedness, and team communication are critical to preventing such complications.3

This chapter reviews anatomic considerations, clinical airway assessment in both the emergent and elective settings, and multidisciplinary considerations in airway management. The narrative specifically addresses refinements in equipment and techniques that allow for safer patient care. In addition, as systems-based initiatives and practice-based learning are critical, we highlight some of the concepts that allow members of the airway team to improve their fund of knowledge and technical skills related to airway management.

UPPER AIRWAY ANATOMY AND CLINICAL RELEVANCE

The approach to any clinical problem begins with a solid understanding of both normal anatomy and alterations associated with disease-specific pathophysiology. Knowledge of the types of anatomic variations and specific pathologic entities that can alter the anatomy are fundamental to safe and effective airway management.

The “upper” airway is defined as the portion of the head and neck where there is airflow. Thus, the nasal cavity, oral cavity, pharynx, larynx, and upper trachea constitute the upper airway. Each of these anatomic sites has several subsites. The nasal cavity is divided into left and right sides by the nasal septum and includes the superior, middle, and inferior turbinates. The choana is the boundary between the nasal cavity and the nasopharynx. The oral cavity includes the teeth, mandible, and oral tongue; the oropharynx includes the base of tongue, tonsillar structures, posterior oropharynx, and soft palate. The area at the junction of the oropharynx and the nasopharynx is particularly important. As there is minimal cartilaginous support in this area, collapse of the pharyngeal wall is common with induction of anesthesia and may impair mask ventilation.

The larynx (Fig. 145-1) consists of supraglottic structures (the epiglottis, false vocal cords, and aryepiglottic folds) and the glottis (the true vocal cords). Below the glottis is the subglottis, which transitions to the trachea below the cricoid cartilage. The vallecula is considered part of the pharynx and constitutes a depression between the lingual surface of the epiglottis and the root of the base of the tongue. It is an important landmark for intubation, since Macintosh-style laryngoscope blades are designed to fit into the area, to lift the larynx, and to expose the glottis region. The epiglottis can also be lifted on the laryngeal surface, as is typically done using straight-blade and ...

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