Anatomic and physiopathologic changes affecting the airway of the elderly patient: implications for geriatric-focused airway management

Figures & data

Figure 1 Anatomical variation in young and elderly.

Notes: (A) Teeth present and undamaged; (B) thick lips, ability to open mouth widely; (C) long, thick, muscular neck; (D) damaged and missing teeth, thin and fragile lips, inability to open mouth widely; (E) posterior view of oropharyngeal cancer at base of tongue; (F) short, stiff neck; and (G) thyroid mass.

Table 1 Airway devices/management strategies for the elderly patient

Anatomic site	Most common problems	Recommendations
Nasal/oral cavity
Nasal	Nasal polyps	– Ask patient which nostril he/she breathes out of best
		– Use lubrication or local anesthetic gel to aid passage of nasopharyngeal airways or nasal intubation
Lips	Dry/fragile and prone to lacerations	– Place ointment on lips
		– Use an intubating device with less force (VL)
	Lack of BMV seal due to orbicularis oris atrophy	– Consider use of an SLD for ventilation
Teeth	Loose teeth prone to breaking off	– Use a device with less force (VL)
		– Have McGill’s forceps available
	Lack of BMV seal due to being edentulous	– Use an SLD for ventilation
Tongue	Aspiration due to supra/infrahyoid muscle atrophy	– Maintain CPAP <20 cm H2O
		– Use an SLD for ventilation
	Poor vocal cord visualization due to Candida infection	– Use VL for better visualization
Oral cavity	Less secretions/frail and prone to bleeding	– Use a device with less force (VL)
		– Have a suction device available
	Trauma to oral lesions may be worsened with devices	– Use a device with less force (VL)
Pharyngeal/laryngeal
Oropharynx	Poor vocal cord visualization due to tumors/masses	– Use a device with more maneuverability (FFB)
Pharynx	Fat accumulation increasing risk of a collapse/apnea	– Place in reverse Trendelenburg
		– Provide CPAP
	Redundant tissue making visualization of vocal cords difficult	– Use VL for better visualization
Epiglottis	Limited movement increasing risk of aspiration	– Consider awake FFB
	Difficult to move anteriorly due to floppiness	– Use a Miller blade instead of Mac for DL
Larynx	Aspiration risk due to decrease in sensitivity	– Maintain CPAP <20 cm H2O
		– Use an SLD for ventilation
Miscellaneous systems
Head (Cognitive)	Alzheimer’s causing lack of cooperation	– If FFB is needed, perform asleep rather than awake
	Parkinson’s causing vocal cord bowing	– Use a smaller ETT to prevent damage to vocal cords
	Rigidity if Parkinson’s medications are not taken prior	– Use a device with more maneuverability (FFB)
	Risk of aspiration due to Parkinson’s	– Maintain CPAP <20 cm H2O
		– Use an SLD for ventilation
Neck	Decreased neck ROM due to rheumatoid arthritis, cervical myelopathy, scars, radiation, and/or thyroid masses	– With limited ROM of neck, use VL
		– With no ROM in neck, use FFB
Cardiac	Arterial stiffness causing cardiovascular lability	– Consider administration of β-blockers
	Increase in sympathetic nervous system causing tachycardia during intubation	– Use a device with less force (VL)
Lungs	Risk of desaturation due to ventilation/perfusion mismatch, stiff alveoli, poor tethering, and/or COPD	– Preoxygenate with end-tidal O2>0.8
		– Attempt to limit intubation <2 minutes
	Decreased expansion of chest wall, possibly leading to hypercarbia	– Position in reverse Trendelenburg
		– Avoid hypercarbia
	Bronchitis and/or emphysema causing wheezing and potential bronchospasm	– Use a bronchodilator prior to intubation
Gastrointestinal	Aspiration risk due to decreased esophageal motility, GERD, and/or achalasia	– Keep CPAP <20 cm H2O
		– Use an SLD for ventilation
Integumentary	Frail skin and prone to bleeding	– Use a device with less force (VL)
		– Keep suction and/or gauze available
	Scleroderma making it difficult to open mouth	– Use a device with maneuverability (FFB)
	Scleroderma making it hard to tape ETT	– Use a soft beard strap instead of tape

Abbreviations: BMV, bag mask ventilation; CPAP, continuous positive airway pressure; DL, direct laryngoscopy; ETT, endotracheal tube; FFB, flexible fiberoptic bronchoscope; GERD, gastroesophageal reflux disease; ROM, range of motion; SLD, supralaryngeal device; VL, video laryngoscope.

Figure 2 Devices for airway management.

Notes: Conventional: 1: oral airway; 2: mask; 3: Miller laryngoscope; 4: Macintosh laryngoscope; 5: endotracheal tube. Advanced: 6: supralaryngeal device; 7: video laryngoscope. Specialized: 8: flexible fiberoptic bronchoscope. Additional: 9: tongue depressor; 10: bite block; 11: bronchodilator; 12: nasopharyngeal airway.