1. Airway management in morbid obese patients J P Mulier MD PhD
Airway management in morbid obese patients J P Mulier MD PhD
Sint Jan Brugge-Oostende
Bariatric center of Excellence
EMCOP airway management

2. EMCOP airway management

3. Is mask ventilation safe in morbid obese patients?
Intra abdominal pressure correlates with BMI
J P Mulier EJA 2009
Abnormal reflux scores correlates with BMI
Fisher B. Dig Dis Sci. 1999
During abdominal compression, the rate of LES pressure increase is faster than that of the gastric pressure, suggesting an active contraction at the esophagogastric junction
R Mittal Am J Physiol Gastrointest Liver Physiol 1990
EMCOP airway management

4. BMI effect on abdominal P/V relation
J Mulier ISPUB 2009
Pressure volume relation is linear
PV0 and E define each patient
J Mulier IFSO 2007
EMCOP airway management

5. Is mask ventilation safe in morbid obese patients?
A deLeon
Body position and esophageal sphincter pressures in obese patients during anesthesia
Acta Anesth Scand 2010
EMCOP airway management

6. Mask ventilation Safe to ventilate by mask? High mask pressures needed
Rapid sequence induction?
Awake intubation?
Safe to ventilate by mask?
Yes <-> No …Never if
High intra abdominal pressures PV0 up 12
But LES prevents regurgitation …
High mask pressures needed
Volutrauma risk post intubation
CPAP by mask before induction
non-invasive CPAP: the SUPER-Boussignac
EMCOP airway management

7. Is Sellick maneuver usefull?
Displacement of esophagus
Lowering of LES = less protection?
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8. Original Sellick maneuver
Hypoharynx and not esophagus is compressed!
EMCOP airway management

9. EMCOP airway management

10. Help position: head elevated laryngoscopy position
J. Brodsky: obese patients: difficult in mask ventilation
No difference in difficult intubation if properly positioned.
Brodsky, J. B. et al. Anesth Analg 2003;96: a
J. Brodsky A morbidly obese patient will be in position for direct laryngoscopy when an imaginary horizontal line can be drawn from the sternal notch to the external auditory meatus
EMCOP airway management

11. EMCOP airway management
Intubation is not difficult if… difficult mask ventilation = difficult intubation
Proper positioning (help) normalizes the risk of difficult intubation. ( Brodsky)
Trachea pharyngeal alignment by
Head pillow
Thorax elevation
Use of an inflatable pillow, safety bird is simple and effective to rotate thoracic column.
Video laryngoscopy must be available
EMCOP airway management
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12. EMCOP airway management
Video laryngoscopy
EMCOP airway management

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intubation
EMCOP airway management

14. Sterno mental distance without safety bird
Normal position
Use of inflatable pillow
Mulier J.P., Dillemans B. Intubation time with and without inflatable intubation device
Eur J Anesthesia 2007 Suppl
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15. Effect of safety bird Trachea – pharyngeal angle > 30° < 30°
> 30° < 30°
No safety bird with safety bird
Mulier J.P., Dillemans B. CT analysis of the safety bird in mobid obese patients
Obes Surg :444
EMCOP airway management

16. EMCOP airway management
Intubation
Prediction of difficult intubation
Not BMI or obesity
based on neck circumference > 50 cm
Good Positioning is important
Risk not higher if properly positioned
Help position (J Brodsky)
Safety bird (JPMulier)
Awake Bronchoscopic intubation?
Not needed anymore?
Video laryngoscopy must be available
EMCOP airway management

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Knowledge test among Anesthesiologist & Intensivists Hyperinflation of the cuff can lead to…
Courtesy S Blot et al. 2009
EMCOP airway management 19

20. EMCOP airway management
Knowledge test Cuff pressure is determined most accurately by means of...
Courtesy S Blot et al. 2009
EMCOP airway management 20

21. Practice test Cuff pressure is controlled by
Finger palpation
Manometer control every 8 hours
Continous monitored and automatic adapted
Most often in anesthesia
Most often at intensive care
Minority of intensive care units
Courtesy S Blot et al. 2009
EMCOP airway management 21

22. Microaspiration: also with perfect cuff pressure
Migration of supraglottic material past the ETT cuff into the respiratory tract.
Pictured: inadvertent microaspiration of contrast media after a barium swallow examination in an intubated patient
Microaspiration is the leakage of secretions and foreign material past the cuff. The visual is of an intubated patient after a barium swallow. The contrast media is evident in the left bronchi, which leads us to conclude that microaspiration past the endotracheal tube cuff occurred.
Reproduced from Macrae et al. Br Med J (Clin Res Ed);283:1220 with permission from BMJ Publishing Group Ltd.
EMCOP airway management

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In vitro tests
A B C
Runs througwgh stop on top runs & stop
EMCOP airway management

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Taperguard is a good indication in bariatric surgery to prevent silent aspiration
Bronchoscopic evaluation in morbid obese patients ventilated at > 5 cm H20 peep
No leak
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26. SOS: Complications measured in 1164 surgery patients
Postoperative complications: 13 %
pulmonary complications 6.1 % other complications 4.8
leakage, abscess 2.1
wound complications 1.8
thrombosis, embolism 0.8
bleeding
Complications required reoperation in 2.2 % of the patients.
Reoperations and conversions over 10 years:
Banding 31 %
VBG 21
Gastric bypass 17
Sjostrom N Engl J Med 2007
EMCOP airway management

27. Per-operative silent aspiration
Normal cuffs leak!
Peep is not protecting
To do:
Gel, microcuff or taperguard cuff
Gel not 100% protection
Cuff pressure monitoring and stabilisation at 30 cmH20
Subglottic suctioning
EMCOP airway management

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Ventilation
Peep
never interrupt, keep minimum 5 cmH2O
PCV vs VCV
PCV risk for volutrauma
No outcome difference
PCV only when high airway pressures?
Only when low saturation?
Beach chair and abdominal model
Improves total thoraco pulmonary compliance
Permissive hypercapnia
EMCOP airway management

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32. EMCOP airway management
Hypercapnia
Permissive hypercapnia?
et CO2 is higher in morbid obese patients
Increases cardiac output
Less wound infections
Increases blood pressure
Prevent post operative bleeding
Pressure support easier or needed?
Breathing against ventilator possible
Contra indication: pulmonary hypertension
EMCOP airway management

33. Can anesthesiology help to prevent post op bleeding? Yes
110/ /78
J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin
The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric bypass surgery.
Obes Surg 2007; 17: 1051
EMCOP airway management

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35. PSV is possible even with full muscle relaxation
Diaphragm remains active, enough to trigger ventilator at 0,6 L/min sensitivity
Extra dose of Morfine stops PSV indicating no auto trigger phenomen
PROFOUND MUSCLE RELAXATION DOES NOT DISTURB
PRESSURE SUPPORT VENTILATION.
Mulier J, Blacoe D PGA 2009
EMCOP airway management

36. PSV allows pain therapy optimalisation
Before after extra sufentanil bolus
EMCOP airway management

37. EMCOP airway management
Weaning with PSV
Stimulates own breathing
Possible during muscle relaxation
Maximum morfine loading possible
Continue peep and cpap in spont breathing
Never hypoventilation and hypoxia
Allow rise in et CO2,
less muscle relaxation needed at the end
Not breathing against ventilator
Not disturbing laparoscopic workspace and view
EMCOP airway management

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39. Post op gastric tube aspiration test
Empty stomach pouch to prevent aspiration
Treat if new red blood is detected
EMCOP airway management

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Extubation
Aspiration before extubation is important
Oral cavity
Prevent post extub aspiration
Gastric pouch
Detect intraluminal bleeding
Prevent nausea, vomiting
Supra glottis
Ctu ? Prevent silent aspiration
Extubation during aspiration risk of atelectasis
better under positive airway pressure
EMCOP airway management

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OSA OHS
OSA obstructive sleep apnea
OHS obesity hypoventilation syndrome
See lecture tomorrow
EMCOP airway management

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Become member ESPCOP
Secretary
Luc De baerdemaeker
President
Jan P Mulier
Treasurer
Nick Kennedy
Vice-President
Yigal Leykin
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Second ESPCOP Scientific meeting Multidisciplinarity Pordenone, Italy 18 sept 2010
EMCOP airway management