Presentation on theme: "Difficult Airway Management. Airway management is really easy…. Except when it isnt."— Presentation transcript:
Difficult Airway Management
Airway management is really easy…. Except when it isnt
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
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
… If only they looked this good …
But our options are different
More Difficult Situation:
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
MOST OF OUR PATIENTS ARE ALREADY DIFFICULT AIRWAYS BY OR STANDARDS.
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.
How to identify a difficult airway?
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
Airway Evaluation Past Medical History Decreased cervical mobility Anatomic upper airway abnormalities History of Previous Problems in surgery
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
Dr. Binnions LEMON Law: An easy way to remember multiple tests Look externallyLook externally Evaluate ruleEvaluate rule MallampatiMallampati ObstructionsObstructions Neck mobilityNeck mobility Airway Evaluation
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
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
LEMON Law – Mallampati (difficult direct laryngoscopy Cormack & Lehane grading)
Nasopharyngeal &Oropharyngeal Airways COPA – Cuffed Oral-pharynageal Airway
Flexible Tip Laryngoscope Flexiblade CL (Corazelli-London) Flexible Tip Laryngoscope
BURP backwards upwards right pressure Cricoid pressure vs External Laryngeal Manipulation
Bougie or Eschmann Stylette
Pharyngeal-Tracheal Lumen Airway (PTL)
Laryngeal Mask Airway (LMA)
Intubating LMA (iLMA)
Retrograde Tracheal Intubation
Flexible Fiberoptic Scope
Rigid Fiberoptic Scope Rigid Fiberoptic Scope
Rigid Fiberoptic Scope Bullard Wu Scope
Rigid Fiberoptic Scope Upsher Levitan Scope
Video Laryngoscope Glidescoe McGrath
VIDEO Video Laryngoscope Glidescope
LMA C-Trach Video Laryngoscope
Surgical Airway: Cricothyroidotomy
Quicktrach Emergency Cricothyrotomy
Tran-Tracheal Jet Ventilation (TTJV)
Expired CO2 Confirmation
YELLOW = CO2 PURPLE = NO CO2
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
Difficult Airway Difficult Airway Before intubation Do we have to intubate? CPAP ? PPV with BVM or Demand Valve? Nasal ETT?
Difficult Airway Difficult Airway Management Prearranged Emergency airway trolley available? Most senior staff Emergency airway algorithm Discussion with colleagues in advance. Deliver supplemental O2
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.
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.
Plan A: Alternate Different Length of blade Different Type of Blade Different Position BURP
Plan B: Blind Techniques BVM BVM Bougi Bougi Videolaryngoscope Videolaryngoscope LMA, iLMA LMA, iLMA Combitube Combitube Retrograde intubation? Retrograde intubation? TTJV? TTJV?
Plan C: Cant intubate, Cant ventilate Cricthyrotomy (needle or surgical) Tracheostomy
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
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