IJCM  Vol.7 No.11 , November 2016
Airway Characteristics and Safe Management of Spontaneously Breathing Patients: Risks of Sedation and Analgesia and Changes in Wakefulness
Abstract: The goal of safe airway management is to maintain a patent airway. Lack of knowledge of the anatomical morphology and changes that may occur in the upper airway during sedation and unconsciousness may lead to critical incidents and hazardous complications. This review focuses on the risks of sedation and analgesia and changes in wakefulness on airway patency in spontaneously breathing patients. Furthermore, key elements of airway management are presented and discussed.
Cite this paper: Reber, A. (2016) Airway Characteristics and Safe Management of Spontaneously Breathing Patients: Risks of Sedation and Analgesia and Changes in Wakefulness. International Journal of Clinical Medicine, 7, 726-735. doi: 10.4236/ijcm.2016.711079.

[1]   American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists (2002) Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology, 96, 1004-1017.

[2]   Schwab, R.J., Gefter, W.B., Pack, A.I. and Hoffman, E.A. (1993) Dynamic Imaging of the Upper Airway during Respiration in Normal Subjects. Journal of Applied Physiology, 74, 1504-1514.

[3]   Schwab, R.J. (1996) Properties of Tissues Surrounding the Upper Airway. Sleep, 19, S170-S174.

[4]   Malhotra, A., Huang, Y., Fogel, R.B., Pillar, G., Edwards, J.K., Kikinis, R., Loring, S.H. and White, D.P. (2002) The Male Predisposition to Pharyngeal Collapse: Importance of Airway Length. American Journal of Respiratory and Critical Medicine, 166, 1388-1395.

[5]   Trudo, F.J., Gefter, W.B., Welch, K.C., Gupta, K.B., Maislin, G. and Schwab, R.J. (1998) State-Related Changes in Upper Airway Caliber and Surrounding Soft-Tissue Structures in Normal Subjects. American Journal of Respiratory and Critical Care Medicine, 158, 1259-1270.

[6]   Hillman, D.R., Platt, P.R. and Eastwood, P.R. (2010) Anesthesia, Sleep, and Upper Airway Collapsibility. Anesthesiology Clinics, 28, 443-455.

[7]   Cravero, J.P., Beach, M.L., Blike, G.T., Gallagher, S.M., Hertzog, J.H. and Pediatric Sedation Research Consortium (2009) The Incidence and Nature of Adverse Events during Pediatric Sedation/Anesthesia with Propofol for Procedures Outside the Operating Room: A Report from the Pediatric Sedation Research Consortium. Anesthesia & Analgesia, 108, 795-804.

[8]   Evans, R.G., Crawford, M.W., Noseworthy, M.D. and Yoo, S.J. (2003) Effect of Increasing Depth of Propofol Anesthesia on Upper Airway Configuration in Children. Anesthesiology, 99, 596-602.

[9]   Mahmoud, M., Gunter, J., Donnelly, L.F., Wang, Y., Nick, T.G. and Sadhasivam, S. (2009) A Comparison of Dexmedetomidine with Propofol for Magnetic Resonance Imaging Sleep Studies in Children. Anesthesthesia & Analgesia, 109, 745-753.

[10]   Dewachter, P., Mouton-Faivre, C., Castells, M.C. and Hepner, D.L. (2011) Anesthesia in the Patient with Multiple Drug Allergies: Are all Allergies the Same? Current Opinion in Anesthesiology, 24, 320-325.

[11]   Ehsan, Z., Mahmoud, M., Shott, S.R., Amin, R.S. and Ishman, S.L. (2016) The Effects of Anesthesia and Opioids on the Upper Airway: A Systematic Review. Laryngoscope, 126, 270-284.

[12]   Lu, J., Nelson, L.E., Franks, N., Maze, M., Chamberlin, N.L. and Saper, C.B. (2008) Role of Endogenous Sleep-Wake and Analgesic Systems in Anesthesia. The Journal of Comparative Neurology, 508, 648-662.

[13]   Green, S.M., Rothrock, S.G., Lynch, E.L., Ho, M., Harris, T., Hestdalen, R., Hopkins, G.A., Garrett, W. and Westcott, K. (1998) Intramuscular Ketamine for Pediatric Sedation in the Emergency Department: Safety Profile in 1022 Cases. Annals of Emergency Medicine, 31, 688-697.

[14]   Mosier, J.M., Joshi, R., Hypes, C., Pacheco, G., Valenzuela, T. and Sakles, J.C. (2015) The Physiologically Difficult Airway. Western Journal of Emergency Medicine, 16, 1109-1117.

[15]   Adams, L., Butas, S. and Spurlock Jr., D. (2015) Capnography (ETCO2), Respiratory Depression, and Nursing Interventions in Moderately Sedated Adults Undergoing Transesophageal Echocardiography (TEE). Journal of Perianesthesia Nursing, 30, 14-22.

[16]   Isono, S., Tanaka, A. and Nishino, T. (2002) Lateral Position Decreases Collapsibility of the Passive Pharynx in Patients with Obstructive Sleep Apnea. Anesthesiology, 97, 780-785.

[17]   Litman, R.S., Wake, N., Chan, L.M., McDonough, J.M., Sin, S., Mahboubi, S. and Arens, R. (2005) Effect of Lateral Positioning on Upper Airway Size and Morphology in Sedated Children. Anesthesiology. 103, 484-488.

[18]   Collins, J.S., Lemmens, H.J., Brodsky, J.B., Brock-Utne, J.G. and Levitan, R.M. (2004) Laryngoscopy and Morbid Obesity: A Comparison of the “Sniff” and “Ramped” Positions. Obesity Surgery, 14, 1171-1175.

[19]   Benumof, J.L. (2000) Patient in “Sniffing Position”. Anesthesiology, 93, 1365-1366

[20]   Lewanda, A.F., Matisoff, A., Revenis, M., Harahsheh, A., Futterman, C., Nino, G., Greenberg. J., Myseros, J.S., Rosenbaum, K.N. and Summar, M. (2016) Preoperative Evaluation and Comprehensive Risk Assessment for Children with Down Syndrome. Paediatric Anaesthesia, 26, 356-362.

[21]   Shorten, G.D., Armstrong, D.C., Roy, W.I. and Brown, L. (1995) Assessment of the Effect of Head and Neck Position on Upper Airway Anatomy in Sedated Paediatric Patients Using Magnetic Resonance Imaging. Pediatric Anesthesia, 5, 243-248.

[22]   Vialet, R., Nau, A., Chaumoître, K. and Martin, C. (2008) Effects of Head Posture on the Oral, Pharyngeal and Laryngeal Axis Alignment in Infants and Young Children by Magnetic Resonance Imaging. Paediatric Anaesthesia, 18, 525-531.

[23]   Moustafa, M.A., Emara, D.M. and Nouh, M.R. (2015) Effect of a Neck Collar on Upper Airway Size in Children Sedated with Propofol-Midazolam Combination during Magnetic Resonance Imaging. Paediatric Anaesthesia, 25, 421-427.

[24]   Isono, S., Tanaka, A., Sho, Y., Konno, A. and Nishino, T. (1995) Advancement of the Mandible Improves Velopharyngeal Airway Patency. Journal of Applied Physiology, 79, 2132-2138.

[25]   Paal, P., Niederklapfer, T., Keller, C., von Goedecke, A., Luckner, G., Pehboeck, D., Mitterlechner, T., Herff, H., Riccabona, U. and Wenzel, V. (2010) Head-Position Angles in Children for Opening the Upper Airway. Resuscitation, 81, 676-678.

[26]   Ishikawa, T., Isono, S., Aiba, J., Tanaka, A. and Nishino, T. (2002) Prone Position Increases Collapsibility of the Passive Pharynx in Infants and Small Children. American Journal of Respiratory and Critical Care Medicine, 166, 760-764.

[27]   Safiruddin, F., Koutsourelakis, I. and de Vries, N. (2015) Upper Airway Collapse during Drug Induced Sleep Endoscopy: Head Rotation in Supine Position compared with Lateral Head and Trunk Position. European Archives of Oto-Rhino-Laryngology, 272, 485-488.

[28]   Reber, A., Paganoni, R. and Frei, F.J. (2001) Effect of Common Airway Manoeuvres on Upper Airway Dimensions and Clinical Signs in Anaesthetized, Spontaneously Breathing Children. British Journal of Anaesthesia, 86, 217-222.

[29]   Reber, A., Bobbià, S.A., Hammer, J. and Frei F.J. (2001) Effect of Airway Opening Manoeuvres on Thoraco-Abdominal Asynchrony in Anaesthetized Children. European Respiratory Journal, 17, 1239-1243.

[30]   Shelton, K.E., Woodson, H., Gay, S. and Suratt, P.M. (1993) Pharyngeal Fat in Obstructive Sleep Apnea. American Revue of Respiratory Disease, 148, 462-466.

[31]   Roth, B., Magnusson, J., Johansson. I., Holmberg, S. and Westrin, P. (1998) Jaw Lift—A Simple and Effective Method to Open the Airway in Children. Resuscitation, 39, 171-174.

[32]   Von Ungern-Sternberg, B.S., Erb, T.O. and Frei, F.J. (2005) Jaw Thrust Can Deteriorate Upper Airway Patency. Acta Anaesthesiologica Scandinavica, 49, 583-585.

[33]   Atkins, D.L., Berger, S., Duff, J.P., Gonzales, J.C., Hunt, E.A., Joyner, B.L., Meaney, P.A., Niles, D.E., Samson, R.A. and Schexnayder, S.M. (2015) Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 132, S519-S525.

[34]   Von Ungern-Sternberg, B.S., Erb, T.O., Reber, A. and Frei F.J. (2005) Opening the Upper Airway-Airway Maneuvers in Pediatric Anesthesia. Paediatric Anaesthesia, 15, 181-189.

[35]   Prasarn, M.L., Horodyski, M., Scott, N.E., Konopka, G., Conrad, B. and Rechtine, G,R. (2014) Motion Generated in the Unstable Upper Cervical Spine during Head Tilt-Chin Lift and Jaw Thrust Maneuvers. The Spine Journal, 14, 609-614.

[36]   Oto, J., Li, Q., Kimball, W.R., Wang, J., Sabouri, A.S., Harrell, P.G., Kacmarek, R.M. and Jiang, Y. (2013) Continuous Positive Airway Pressure and Ventilation Are More Effective with a Nasal Mask than a Full Face Mask in Unconscious Subjects: A Randomized Controlled Trial. Critical Care, 17, R300.

[37]   Bruppacher, H., Reber, A., Keller, J.P., Geiduschek, J., Erb, T.O. and Frei, F.J. (2003) The Effects of Common Airway Maneuvers on Airway Pressure and Flow in Children undergoing Adenoidectomies. Anesthesia & Analgesia, 97, 29-34.

[38]   Perilli, V., Sollazzi, L., Bozza, P., Modesti, C., Chierichini, A., Tacchino, R.M. and Ranieri, R. (2000) The Effects of the Reverse Trendelenburg Position on Respiratory Mechanics and Blood Gases in Morbidly Obese Patients during Bariatric Surgery. Anesthesia & Analgesia, 91, 1520-1525.

[39]   Genta, P.R., Schorr, F., Eckert, D.J., Gebrim, E., Kayamori, F., Moriya, H.T., Malhotra, A. and Lorenzi-Filho, G. (2014) Upper Airway Collapsibility Is Associated with Obesity and Hyoid Position. Sleep, 37, 1673-1678.

[40]   Ciscar, M.A., Juan, G., Martínez, V., Ramón, M., Lloret, T., Mínguez, J., Armengot, M., Marín, J. and Basterra, J. (2001) Magnetic Resonance Imaging of the Pharynx in OSA Patients and Healthy Subjects. European Respiratory Journal, 17, 79-86.

[41]   Pien, G.W., Keenan, B.T., Marcus, C.L., Staley, B., Ratcliffe, S.J., Jackson, N.J., Wieland, W., Sun, Y. and Schwab, R.J. (2016) An Examination of Methodological Paradigms for Calculating Upper Airway Critical Pressures during Sleep. Sleep, 39, 977-987.

[42]   Shin, C.H., Zaremba, S., Devine, S., Nikolov, M., Kurth, T. and Eikermann, M. (2016) Effects of Obstructive Sleep Apnoea Risk on Postoperative Respiratory Complications: Protocol for a Hospital-Based Registry Study. BMJ Open, 6, e008436.

[43]   McNicholas, W.T., Bonsignore, M.R., Lévy, P. and Ryan, S. (2016) Mild Obstructive Sleep Apnoea: Clinical Relevance and Approaches to Management. The Lancet Respiratory Medicine, 4, 826-834.

[44]   Sanders, M.H., Kern, N.B., Stiller, R.A., Strollo Jr., P.J., Martin, T.J. and Atwood Jr., C.W. (1994) CPAP Therapy via Oronasal Mask for Obstructive Sleep Apnea. Chest, 106, 774-779.