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Difficult Airway Management. Airway management is really easy…. Except when it isnt.

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Presentation on theme: "Difficult Airway Management. Airway management is really easy…. Except when it isnt."— Presentation transcript:

1 Difficult Airway Management

2 Airway management is really easy…. Except when it isnt

3 DEFFINATION Difficult Intubation is: Failure to intubate with conventional laryngoscopy after an optimal/best attempt with: Reasonable experienced laryngoscopist Reasonable experienced laryngoscopist No significant resistive muscle tone No significant resistive muscle tone Use of optimal sniffing position Use of optimal sniffing position Use of external laryngeal manipulation Use of external laryngeal manipulation Change of laryngoscope balde type a single time, and Change of laryngoscope balde type a single time, and Change of laryngoscope balde length a single time Change of laryngoscope balde length a single time

4 PREVALENCE Failed tracheal intubation 0.05 – 0.35 % Failed tracheal intubation with inadequate mask ventilation0.01 – 0.03 % This is in OR when: Plan in advance Plan in advance Cant get airway.. awaken patient.. Regroup Cant get airway.. awaken patient.. Regroup go for coffee go for coffee

5 … If only they looked this good …

6 But our options are different

7 More Difficult Situation:

8 What makes it difficult in emergency situation Training/requirements Non-controlled settings Limited pre-procedural evaluation Hypoxia, hypotension, agitation, dynamic medical conditions Numerous logistical & implementation issues

9 MOST OF OUR PATIENTS ARE ALREADY DIFFICULT AIRWAYS BY OR STANDARDS.

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.

11 How to identify a difficult airway?

12 We will not talk about The basic anatomy of the Airway The basic anatomy of the Airway BLS airway maneuvers and Endotracheal Intubation by Oral and Nasal means BLS airway maneuvers and Endotracheal Intubation by Oral and Nasal means The concept and procedure of RSI The concept and procedure of RSI

13 Airway Evaluation Past Medical History Decreased cervical mobility Anatomic upper airway abnormalities History of Previous Problems in surgery

14 Predictors of difficult mask ventilation BONES: (two or more) Beard Beard Obesity with BMI > 26 Obesity with BMI > 26 No teeth No teeth Elderly > 55 Elderly > 55 Snorers Snorers Airway Evaluation

15 Dr. Binnions LEMON Law: An easy way to remember multiple tests Look externallyLook externally Evaluate ruleEvaluate rule MallampatiMallampati ObstructionsObstructions Neck mobilityNeck mobility Airway Evaluation

16 LEMON Law - Look externally Obesity or very small. Obesity or very small. Short Muscular neck Short Muscular neck Large breasts Large breasts Prominent Upper Incisors (Buck Teeth) Prominent Upper Incisors (Buck Teeth) Receding Jaw (Dentures) Receding Jaw (Dentures) Burns Burns Facial Trauma Facial Trauma S/S of Anaphylaxis S/S of Anaphylaxis Stridor Stridor Airway Evaluation

17 LEMON Law - Evaluate rule Mouth opening 3 fingers Mouth opening 3 fingers Tip of the chin to the hyoid bone 3 fingers Tip of the chin to the hyoid bone 3 fingers Hyoid bone to the top of the thyroid cartilage 2 fingers Hyoid bone to the top of the thyroid cartilage 2 fingers Airway Evaluation

18 LEMON Law – Mallampati (difficult direct laryngoscopy Cormack & Lehane grading)

19 Airway Evaluation LEMON Law - Obstructions Blood Blood Vomitus Vomitus Teeth Teeth Tumers Tumers Epiglotitis Epiglotitis

20 LEMON Law - Neck mobility Prior condition Prior condition Surgery Surgery Rheumatoid arthritis Rheumatoid arthritis Osteoarthritis Osteoarthritis Others Others Airway Evaluation

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22 What alternative tools do we have?

23 Airway Rescue Tools

24 Bag valve mask Bag valve mask Combitube Combitube LMA LMA Intubation LMA Intubation LMA Fiberoptic: rigid, flexible Fiberoptic: rigid, flexible Lightwand Lightwand Bougie Bougie Transtracheal jet Transtracheal jet Retrograde Retrograde Cricothyrotomy Cricothyrotomy Tracheostomy Tracheostomy

25 Nasopharyngeal &Oropharyngeal Airways COPA – Cuffed Oral-pharynageal Airway

26 Laryngoscopes

27 Flexible Tip Laryngoscope Flexiblade CL (Corazelli-London) Flexible Tip Laryngoscope

28 BURP backwards upwards right pressure Cricoid pressure vs External Laryngeal Manipulation

29 Bougie or Eschmann Stylette

30 Lighted Stylette

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32 Combitube Airway

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34 Pharyngeal-Tracheal Lumen Airway (PTL)

35 Laryngeal Mask Airway (LMA)

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40 Laryngeal-Tracheal Airway

41 Intubating LMA (iLMA)

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46 Retrograde Tracheal Intubation

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48 Flexible Fiberoptic Scope

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50 Rigid Fiberoptic Scope Rigid Fiberoptic Scope

51 Rigid Fiberoptic Scope Bullard Wu Scope

52 Rigid Fiberoptic Scope Upsher Levitan Scope

53 Video Laryngoscope Glidescoe McGrath

54 VIDEO Video Laryngoscope Glidescope

55 Video Laryngoscope

56 LMA C-Trach Video Laryngoscope

57 Surgical Airway: Cricothyroidotomy

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60 Quicktrach Emergency Cricothyrotomy

61 Tran-Tracheal Jet Ventilation (TTJV)

62 TTJV

63 Awake Intubation

64 Expired CO2 Confirmation

65 YELLOW = CO2 PURPLE = NO CO2

66 Difficult Airway Specific strategies: Appreciate the importance of developing a primary and secondary approachAppreciate the importance of developing a primary and secondary approach Identify fundemental prenciples, as adapted from ASA Difficult Airway AlgorithmIdentify fundemental prenciples, as adapted from ASA Difficult Airway Algorithm Know when to consider an airway failed and what takes priority when an airway is failedKnow when to consider an airway failed and what takes priority when an airway is failed

67 Difficult Airway Difficult Airway Before intubation Do we have to intubate? CPAP ? PPV with BVM or Demand Valve? Nasal ETT?

68 Difficult Airway Difficult Airway Management Prearranged Emergency airway trolley available? Most senior staff Emergency airway algorithm Discussion with colleagues in advance. Deliver supplemental O2

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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 dont get the tube? Plans A, B and C Plans A, B and C Know this answer before you tube. Know this answer before you tube.

74 Plan A: Alternate Different Length of blade Different Type of Blade Different Position BURP

75 Plan B: Blind Techniques BVM BVM Bougi Bougi Videolaryngoscope Videolaryngoscope LMA, iLMA LMA, iLMA Combitube Combitube Retrograde intubation? Retrograde intubation? TTJV? TTJV?

76 Plan C: Cant intubate, Cant ventilate Cricthyrotomy (needle or surgical) Tracheostomy

77 1 alternative 2 alternative 3 alternative 4 alternative 1 Manipulation of airway different blade, bugie 2 LMA, ILMA, Combitube Bougi, videolaryngoscope 3 Trantracheal Jet Ventilation? Retrograde intubation? 4 Cricothireotomy, Tracheostomy Difficult Airway

78 Airway Rescue

79 Pearls of Airway Management Be familiar with all airway rescue tools and techniques Recognize the difficult airway If you cant intubate – Bag! If at first you dont succeed, change something Dont turn difficult airways into failed airways Plan ahead, and communicate that plan Get help early, often

80 Mandibular Aplasia Thank you!


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