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

Abstract

There are many anatomical, physiopathological, and cognitive changes that occur in the elderly that affect different components of airway management: intubation, ventilation, oxygenation, and risk of aspiration. Anatomical changes occur in different areas of the airway from the oral cavity to the larynx. Common changes to the airway include tooth decay, oropharyngeal tumors, and significant decreases in neck range of motion. These changes may make intubation challenging by making it difficult to visualize the vocal cords and/or place the endotracheal tube. Also, some of these changes, including but not limited to, atrophy of the muscles around the lips and an edentulous mouth, affect bag mask ventilation due to a difficult face-mask seal. Physiopathologic changes may impact airway management as well. Common pulmonary issues in the elderly (eg, obstructive sleep apnea and COPD) increase the risk of an oxygen desaturation event, while gastrointestinal issues (eg, achalasia and gastroesophageal reflux disease) increase the risk of aspiration. Finally, cognitive changes (eg, dementia) not often seen as related to airway management may affect patient cooperation, especially if an awake intubation is required. Overall, degradation of the airway along with other physiopathologic and cognitive changes makes the elderly population more prone to complications related to airway management. When deciding which airway devices and techniques to use for intubation, the clinician should also consider the difficulty associated with ventilating the patient, the patient’s risk of oxygen desaturation, and/or aspiration. For patients who may be difficult to bag mask ventilate or who have a risk of aspiration, a specialized supralaryngeal device may be preferable over bag mask for ventilation. Patients with tumors or decreased neck range of motion may require a device with more finesse and maneuverability, such as a flexible fiberoptic broncho-scope. Overall, geriatric-focused airway management is necessary to decrease complications in this patient population.

Comparison of the clinical performance of airway management with the i-gel® and laryngeal mask airway SupremeTM in geriatric patients: a prospective and randomized study

“…Second, the existence of teeth can affect the insertion of a SAD. When teeth make a space between the maxilla and mandible, insertion of a SAD may be easier than when no teeth are present [21,22]. In this study, although dental status did not differ between the two groups, a study conducted with all teeth, partial teeth, and edentulous patients in one group could affect the results.…”

“…The ratio of tongue and parapharyngeal fat deposition in the face and the presence of retrognathia can increase along with a decrease in the muscle ratio with aging [7]. In elderly patients whose soft tissue ratio in the face is relatively high and who are prone to sleep apnea [7,21], the i-gel Ⓡ compresses the tongue, whereas insertion of the pre-curved (or fixed shaped) LMA Supreme TM would be difficult because the LMA Supreme TM does not press the lingual soft tissue for proper positioning [10]. In addition, a device of predetermined shape like the LMA Supreme TM , compared to the i-gel Ⓡ , which has a thermoplastic elastomer cuff, may have difficulty reflecting the age-related changes.…”

Comparative randomised study of GlideScope® video laryngoscope versus flexible fibre-optic bronchoscope for awake nasal intubation of oropharyngeal cancer patients with anticipated difficult intubation

“…[1] Awake intubation using flexible fibre-optic scope (FFS) is the gold standard technique in anticipated difficult intubation patients. [23] Awake intubation of oropharyngeal cancer patients is usually preferred via nasal rather than oral route to avoid interference with the surgical field.…”

Major trauma in the elderly: The effects of ageing on ED assessment

“…Ageing is associated with decreased respiratory reserve, as lung tissue becomes increasingly inelastic and alveolar function diminishes ( Johnson, Botros, Groban, & Bryan, 2015). Chronic lung diseases such as emphysema or COPD increase the risk of respiratory failure in the elderly.…”