1. DIFFICULT AIRWAY MANAGEMENT
Tools and Tactics for Success

2. First Case of the Day

3. ASA Definition The Difficult Airway- Difficult to Ventilate-
is defined as the clinical situation in which a conventionally trained Anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both
Difficult to Ventilate-
is when signs of inadequate ventilation could not be reversed by mask ventilation or oxygen saturation could not be maintained above 90%
Difficult to Intubate-
is when a trained Anesthetist using conventional laryngoscope take’s more than 3 attempts

4. DISCUSSION 4th National Audit Project NAP4
Causes of difficult intubation
Basic airway evaluation (Lemon Law )
Airway Management A-B-C
Gallery of tools
Extubation of the Difficult Airway
ASA Difficult airway algorithm

5. Degrees of Airway Difficulty

6. Difficult Mask Ventilation
Overlap
Difficult Mask Ventilation

7. Overlap
Difficult Mask Ventilation
Difficult
SGA

8. Triple Failure Difficult Mask Ventilation Difficult Intubation
Difficult SGA
Difficult
Intubation
DANGER ZONE

9. An Emergent Surgical Airway is Not Always Assured
Difficult Mask Ventilation
Difficult surgical airway
Difficult
Intubation
Danger Zone

10. 4th National Audit Project NAP4
Sept 2008-Sept 2009 estimated 2,900,000 GA performed in the UK
Data collected on 114,904 GA’s from 309 hospitals over a 2 week period
184 serious airway complications, including:
-Death (14)
-Brain Damage
-Emergent Surgical Airway
-Unexpected ICU admission

11. NAP4 Lessons Learned PRIMARY PROBLEMS Aspiration #1
Extubation Problems
Tracheal Intubation
Delayed Intubation
Failed Intubation
Can’t Intubate Can’t Ventilate

12. NAP4 Lessons Learned
Poor Airway Assessment & Poor Planning contributed to Poor Outcomes
Failure to match strategy to assessment (technique)
Failure to have prepared strategy (plan B and C)

13. NAP4 Lessons Learned
Emergency Percutaneous Cricothyrotomy failed 60% of the time

14. NAP4 Lessons Learned A common theme was “failure to plan for failure”
In some cases when airway management was unexpectedly difficult the response was unstructured. In these cases outcomes were generally poor.
The project identified numerous cases where awake fiber-optic intubation was indicated but not used

15. NAP4 Lessons Learned
Aspiration was the single most common cause of death in anesthesia events
Importantly most aspirations occur due to failure to recognize risk factors and failure to adjust the anesthetic technique accordingly
Aspiration remains the most frequent cause of airway related deaths during anesthesia.

16. NAP4 Lessons Learned
One third of the events occurred during emergence or in recovery. Obstruction was the common cause in these events
Recommendations:
Nasal Trumpets
Oral Airway
Airway exchange catheter
SGA prior to removal of ETT (Bailey Maneuver)
Awaken patient with SGA in place

17. Predictors of Difficult Mask Ventilation
Beard
OSA
Obesity
Male Gender
Mallampati class III or IV
Neck Circumference

18. Predictors of Difficult Intubation
Inadequate Preoperative Assessment.
History of difficult intubation
Inadequate equipment
Experience not enough.
Poor technique.
Increased Age
Mallampati III or IV

19. Anatomical Factors Affecting Laryngoscopy
Neck Circumference (Single Major Predictor in Obese)
Short Neck.
Protruding incisor teeth.
Long high arched palate.
Increase in either anterior depth or Posterior depth of the mandible decrease in Atlanto Occipital distance
Limited cervical range of motion
Small mouth opening
Temporomandibular joint pathology

20. Basic Airway Evaluation in All Patients
Previous anesthetic problems
General appearance of the neck, face, maxilla and mandible
Jaw movements
Head extension and movements
The teeth and oropharynx
The soft tissues of the neck
Recent chest and cervical spine x-rays

21. Think L-E-M-O-N When Assessing a Difficult Airway
Look externally.
Evaluate the rule.
Mallampati.
Obstruction?
Neck mobility.

22. L: Look Externally Obesity or very small. Short Muscular neck
Large breasts
Prominent Upper Incisors (Buck Teeth)
Receding Jaw (Dentures)
Burns
Facial Trauma
Stridor
Macroglossia (Lg Tongue)

23. E-Evaluate the 3-3-2 Rule 3 fingers fit in mouth
3 fingers fit from mentum to hyoid cartilage
2 fingers fit from the floor of the mouth to the top of the thyroid cartilage

24. E-Evaluate the Rule
4/14/2017

25. M- Mallampati classification
Class-II
soft palate, fauces;
Uvula, pillars.
the soft palate, fauces
and uvula
Class-III
Class-IV
soft palate and base of uvula
Only hard palate

26. Mallampati ?

27. Cormack & Lehane Grading

28. O-Obstruction
Blood Vomit Teeth Dentures Epiglottis Tumors Foreign Body (piercings)

29. N-Neck mobility -Measurement of Atlanto-Occipital Angle

30. Atlanto-Occipital Angle
Estimates the angle traversed by the occluded surface of the upper teeth
Grade I --- > 35°
Grade II – °
Grade III – 12-21°
Grade IV -- < 12°

31. Thyromental Distance
Measure from upper edge of thyroid cartilage to chin with the head fully extended.
A short thyromental distance equates with an anterior larynx
Greater than 7 cm is usually a sign of an easy intubation
Less than 6 cm is an indicator of a difficult airway
Relatively unreliable test unless combined with other tests

32. Thyromental Distance

33. MANAGEMENT PLAN OF ANTICEPATED DIFFICULT AIRWAY
Discussion with colleagues in advance
Equipment tested before
Senior help backup
Definite initial plan (A) for ventilation and intubation
Definite plan (B) than option of awake intubation
Ideal situation surgery team standby

34. Preoxygenation Two Techniques Common in Use: Why Preoxygenate?
Tidal volume breathing (TVB) of 100% oxygen via a tight-fitting face mask for 5 minutes (Preferred Method)
Deep breaths/Vital Capacity 4 times within 0.5 min (Time to desaturation is consistently shorter then preferred method)
Why Preoxygenate?
O2 Consumption Vo2=250ml/min and 2500ml O2 in FRC (after preO2) = 10 minutes to use this O2

35. Airway Management A-B-C
Start with Plan A
If plan A fails-
Go to plan B
If plan B fails-
Go to plan C

36. Plan “A”: (ALTERNATE) Different Length of blade
Different Type of Blade
Different Position
Different Equipment

37. Plan “B”: (BVM and BLIND INTUBATION Techniques )
Mask Ventilation
Bougie
Combi-Tube?
LMA an Option?
Fiberoptic?

38. Plan-C Can’t Intubate.. Can’t Ventilate
Needle Cricothyrotomy
Transtracheal Jet Ventilation
Retrograde Wire Intubation

39. Failure.. Why does it happen
No critical discussion with colleagues about proposed management plan
No request for experienced help
Exaggerated idea of personal ability
Ill-conceived plan A and/or plan B
Poorly executed plan A and/or plan B
Persisting with plan A too long, starting the rescue plan too late
Not involving, and preparing, surgical colleagues

40. GALLERY OF
TOOLS

41. Rigid Laryngoscope Blades Of Alternate Design And Size
Mc Coy
Macintosh
Magill
Miller
Mac Coy
Polio

42. Video Laryngoscopy
Airtraq
McGrath
C-Mac

43. Video Laryngoscopy VL Calls on a Alternative Skill Set
In Critical Situations Unpracticed Techniques may not be Helpful

44. Video Laryngoscopy Use a stylet and shape it to match your VL Blade
Watch the patient not the monitor when
inserting the VL Blade
Trouble passing tube
-Withdraw
-Lift Less
-Drop your angle

45. Video Laryngoscopy Versus Direct Laryngoscopy
Improved Glottic View
Experienced vs Inexperienced
Cost
Standard of the future?
Picture Confirmation?

46. Bullard Rigid Fiberoptic Laryngoscope
Time
Experience
Limited Maneuverability

47. Stylet Devices No Nasal Intubation No Suction Limited to above Cords
Optical Stylet
Lighted Stylet
No Nasal Intubation
No Suction
Limited to above Cords

48. GUM ELASTIC BOUGIE (GEB)
First used in England
Cheap
Good in patients in whom
only epiglottis is visualized

49. Supraglottic Airways SGA
Combitube
LMA C

50. The Esophageal- Tracheal Combitube
Useful as emergency airway
Two lumens allow function whether place in esophagus or trachea
Esophageal balloon minimizes aspiration

51. Laryngeal Mask Airway

52. VARIATIONS OF LMA LMA – Classic (standard) LMA – Flexible (reinforced)
LMA – Unique (disposable LMA)
LMA – Fastrach (intubating LMA)
LMA – C-Trach (Visualization/Intubation)
LMA – Proseal (gastric LMA)

53. LMA – Fastrach (Intubating LMA)
Rigid, anatomically curved, airway tube that is wide enough to accept an 8.0 mm cuffed ETT and is short enough to ensure passage of the ETT cuff beyond the vocal cords
Rigid handle to facilitate one-handed insertion, removal
Epiglottic elevating bar in the mask aperture which elevates the epiglottis as the ETT is passed through
Available in three sizes, one size for children, two sizes for adults

54. LMA C-Trach
Ventilation
Visualization
Intubation

55. LMA-Proseal
High seal pressure - up to 30 cm H20 - Providing a tighter seal against the glottic opening with no increase in mucosal pressure
Provides more airway security
Enables use of PPV in those cases where it may be required
A built-in drain tube designed to channel fluid away and permit gastric access for patients with GERD

56. LMA-Proseal

57. Fiberoptic Aided Intubation
Most Versatile Tool Available for Difficult Intubation
Optical Elements are Small
Visualization Below the Cords
Awake Intubation
Unique Skillset
Lens Contamination
Cost

58. Can’t Ventilate/Cant Intubate

59. Cricothyrotomy Airway established through the Cricothyroid Membrane
Not a Tracheostomy
Large Bore Catheter
Expected skill of the Anesthetist
Contraindicated in Neonates and Children under age 6

60. Transtracheal Jet Ventilation
Maxillofacial, Pharyngeal, or Laryngeal Trauma, Pathology or Deformity
16-Gauge or Larger (16g- tidal volume )
15-30 psi with Insufflation sec.
Specialized systems capable of using Low-pressure O2

61. Retrograde Intubation
Local Anesthesia of the airway, skin wheel at puncture site.
Cricothyrotomy performed with air aspiration
Retrograde wire is advanced until it emerges from the mouth. (Magill Forceps)
Wire is Clamped/Secured at the entry site
ETT advanced over the wire (Many Techniques)
Wire removed leaving ETT in place

62. Retrograde Intubation

63. Extubation of the Difficult Airway

64. Airway Exchange Catheter
Extubation in a controlled manner with a AEC
Well tolerated
Airway can be reintubated
Can deliver Oxygen
Provides an avenue for suction

65. Airway Exchange Catheter
Localize the airway through existing ETT
Mark AEC at required depth (tube depth +3 CM)
Insert AEC and remove ETT
Tape AEC in place
Assess for removal of AEC

66. Bailey Maneuver Exchange of ETT for a LMA Decreased Severity of Cough
Maximum change SBP
Maximum change HR
Sore throat

67. Bailey Maneuver Patient is Deep Oral-pharyngeal suction
Deflated LMA placed behind ETT
LMA cuff inflated
ETT cuff deflated and removed
LMA used for ventilation

68. What's New in the ASA Difficult Airway Algorithm
2003
2013

69. What's New in the ASA Difficult Airway Algorithm
Assess Likelihood and Impact section.
Added:
Difficult Supraglottic airway placement
Separated: Intubation and Laryngoscopy

70. What's New in the ASA Difficult Airway Algorithm
2003
2013
Basic Management Choices:
Video-assisted Laryngoscopy as initial approach to Intubation

71. What's New in the ASA Difficult Airway Algorithm
2003
2013
“LMA” changed to “SGA”

72. What's New in the ASA Difficult Airway Algorithm
2003
2013
Video-Assisted Laryngoscopy: Listed first under Alternative Difficult Intubation Approach

73. What's New in the ASA Difficult Airway Algorithm
2003
2013
Under Invasive Airway Access: Percutaneous airway techniques and jet ventilation remain but are
de-emphasized

74. Two For The Road

75. Two For The Road
Be familiar with alternative intubating techniques and use them on a regular basis in your day to day practice.

76. Two For The Road

77. Questions?

78. Questions?