2 Airway management is really easy…. Except when it isn’t
3 DEFFINATION Difficult Intubation is: Failure to intubate with conventional laryngoscopy after an optimal/best attempt with:Reasonable experienced laryngoscopistNo significant resistive muscle toneUse of optimal sniffing positionUse of external laryngeal manipulationChange of laryngoscope balde type a single time, andChange of laryngoscope balde length a single time3 attempts or > 10 minThis optimal attempt is:
4 prevalence Failed tracheal intubation 0.05 – 0.35 % Failed tracheal intubation with inadequate mask ventilation – 0.03 %This is in OR when:Plan in advanceCan’t get airway .. awaken patient .. Regroupgo for coffee3 attempts or > 10 minThis optimal attempt is:
5 If only they looked this good… Place Axis photo here
6 But our options are different 3 attempts or > 10 minThis optimal attempt is:
8 What makes it difficult in emergency situation Training/requirementsNon-controlled settingsLimited pre-procedural evaluationHypoxia, hypotension, agitation, dynamic medical conditionsNumerous logistical & implementation issues
9 Most of our patients are already “difficult airways” by “OR” Standards. In most cases Pre-hospital airway needs managing regardless of difficulty , and the Paramedic is expected to do that, regardless of difficulty ….so what is the benefit of knowing a Fancy system?
10 The American Society of Anesthesiology (ASA) has noted: “there is strong agreement among consultants that preparatory efforts enhance success and minimize risk”And “The literature provides strong evidence that specific strategies facilitate the management of the difficult airway”Thus identifying a potentially difficult airway is essential to preparation and developing a strategy.To identify a difficult airwayTo prepare alternative toolsTo establish a plan
11 How to identify a difficult airway? To prepare alternative toolsTo establish a plan
12 We will not talk about The basic anatomy of the Airway BLS airway maneuvers and Endotracheal Intubation by Oral and Nasal meansThe concept and procedure of RSIHow can we further identify a difficult airway?
13 Airway Evaluation Past Medical History Decreased cervical mobility Anatomic upper airway abnormalitiesHistory of Previous Problems in surgeryDecreased cervical mobility:Rheumatoid ArthritisAnkylosing Spondylitis: Painful Stiffening of the JointCervical Fixation DevicesKlippel-Fiel Syndrome: Short wide neck, reduction in number of cervical vertebrae, and possible fusion of vertebraeAnatomic upper airway abnormalitiesThyroid or major neck surgeriesPierre Robin Syndrome: Small Jaw, cleft Pallet, No Gag reflex, downward displacement of tongueAcromegaly: Thickening of Jaw, Soft tissue structures of the face, associated with middle ageReduced Jaw MobilityEpiglottitisTumors, Known Abnormal Structures
14 Airway Evaluation Predictors of difficult mask ventilation “BONES”: (two or more)BeardObesity with BMI > 26No teethElderly > 55Snorers
15 Airway EvaluationDr. Binnions LEMON Law: An easy way to remember multiple testsLook externallyEvaluate ruleMallampatiObstructionsNeck mobility
16 Airway Evaluation LEMON Law - Look externally Obesity or very small. Short Muscular neckLarge breastsProminent Upper Incisors (Buck Teeth)Receding Jaw (Dentures)BurnsFacial TraumaS/S of AnaphylaxisStridor
17 Airway Evaluation LEMON Law - Evaluate 3-3-2 rule Mouth opening ≥ 3 fingersTip of the chin to the hyoid bone ≥ 3 fingersHyoid bone to the top of the thyroid cartilage ≥ 2 fingers
18 (difficult direct laryngoscopy Cormack & Lehane grading) Airway EvaluationLEMON Law – Mallampati(difficult direct laryngoscopy Cormack & Lehane grading)Class I: the vocal cords are visibleClass II the vocals cords are only partly visibleClass III only the epiglottis is seenClass IV the epiglottis cannot be seenClass Ivisualization of the soft palate, fauces, uvula, and both anterior and posterior pillarsClass IIvisualization of the soft palate, fauces, and uvulaClass IIIvisualization of the soft palate and the base of the uvulaClass IVsoft palate is not visible at all
27 Flexible Tip Laryngoscope CL (Corazelli-London) Flexible Tip LaryngoscopeFlexible Tip LaryngoscopeFlexiblade
28 Cricoid pressure vs External Laryngeal Manipulation BURP backwards upwards right pressure
29 Bougie or Eschmann Stylette Gum elastic – use as guidewireAdvantagesGives definitive airwayEasy to learnInexpensiveCan be used blindlyDisadvantagesExpertise requires practiceNot recommended in “can’t intubate / can’t ventilate” scenario
30 Lighted Stylette Disadvantages Blind technique May damage airway Usually requires darkened roomExpertise requires practiceAdvantagesMinimal neck movementUseful adjunct to laryngoscopyPortable and inexpensiveUsable in bloody airwayProvides definitive airway
31 Lighted Stylette Disadvantages Blind technique May damage airway Usually requires darkened roomExpertise requires practice
32 Combitube AirwayDouble lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tubeInsert blindly à 90% esophagealInflate proximal balloon: 100 mLInflate distal balloon: 5 –15mL
33 Combitube AirwayDouble lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tubeInsert blindly à 90% esophagealInflate proximal balloon: 100 mLInflate distal balloon: 5 –15mL
61 Tran-Tracheal Jet Ventilation (TTJV) AdvantagesSurgical airway of choice if 8 years or youngerEffectiveCan serve as temporary airway before permanent airwayRelatively simple procedureDisadvantagesSignificant complications if misplacedNeed proper equipmentNeed high-pressure oxygenDoes not protect against aspiration
66 Difficult Airway Specific strategies: Appreciate the importance of developing a primary and secondary approachIdentify fundemental prenciples, as adapted from ASA Difficult Airway AlgorithmKnow when to consider an airway “failed” and what takes priority when an airway is failed
67 Difficult Airway Before intubation Do we have to intubate?CPAP ?PPV with BVM or Demand Valve?Nasal ETT?
68 Difficult Airway Management Prearranged Emergency airway trolley available?Most senior staffEmergency airway algorithmDiscussion with colleagues in advance.Deliver supplemental O2
72 Difficult Airway Uunexpected Difficult Airway Proble Unexpected difficult airway is mostly gone worse because mainly GA is already given including (NMB)Equipment may not be in hand.Senior and back up plan not available.
73 Difficult Airway what are we going to do if we don’t get the tube? Plans “A”, “B” and “C”Know this answer before you tube.
74 Plan A: Alternate Different Length of blade Different Type of Blade Different PositionBURP
75 Plan B: Blind Techniques BVMBougiVideolaryngoscopeLMA, iLMACombitubeRetrograde intubation?TTJV?
76 Plan C: Can’t intubate, Can’t ventilate Cricthyrotomy (needle or surgical)Tracheostomy
77 Difficult Airway 1 Manipulation of airway different blade, bugie 2 LMA, ILMA, CombitubeBougi, videolaryngoscope3Trantracheal Jet Ventilation?Retrograde intubation?4Cricothireotomy, Tracheostomy1alternative234
79 Pearls of Airway Management Be familiar with all airway rescue tools and techniquesRecognize the difficult airwayIf you can’t intubate – Bag!If at first you don’t succeed, change somethingDon’t turn difficult airways into failed airwaysPlan ahead, and communicate that planGet help early, often