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.

Keywords: anesthesia; aspiration; elderly; intubation; oxygenation; ventilation.

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.

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.