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Difficult Airway Management

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Presentation on theme: "Difficult Airway Management"— Presentation transcript:

1 Difficult Airway Management

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 laryngoscopist No significant resistive muscle tone Use of optimal sniffing position Use of external laryngeal manipulation Change of laryngoscope balde type a single time, and Change of laryngoscope balde length a single time 3 attempts or > 10 min This 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 advance Can’t get airway .. awaken patient .. Regroup go for coffee 3 attempts or > 10 min This optimal attempt is:

5 If only they looked this good…
Place Axis photo here

6 But our options are different
3 attempts or > 10 min This optimal attempt is:

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.
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 airway To prepare alternative tools To establish a plan

11 How to identify a difficult airway?
To prepare alternative tools To 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 means The concept and procedure of RSI How can we further identify a difficult airway?

13 Airway Evaluation Past Medical History Decreased cervical mobility
Anatomic upper airway abnormalities History of Previous Problems in surgery Decreased cervical mobility: Rheumatoid Arthritis Ankylosing Spondylitis: Painful Stiffening of the Joint Cervical Fixation Devices Klippel-Fiel Syndrome: Short wide neck, reduction in number of cervical vertebrae, and possible fusion of vertebrae Anatomic upper airway abnormalities Thyroid or major neck surgeries Pierre Robin Syndrome: Small Jaw, cleft Pallet, No Gag reflex, downward displacement of tongue Acromegaly: Thickening of Jaw, Soft tissue structures of the face, associated with middle age Reduced Jaw Mobility Epiglottitis Tumors, Known Abnormal Structures

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

15 Airway Evaluation Dr. Binnions LEMON Law: An easy way to remember multiple tests Look externally Evaluate rule Mallampati Obstructions Neck mobility

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

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

18 (difficult direct laryngoscopy Cormack & Lehane grading)
Airway Evaluation LEMON Law – Mallampati (difficult direct laryngoscopy Cormack & Lehane grading) Class I: the vocal cords are visible Class II the vocals cords are only partly visible Class III only the epiglottis is seen Class IV the epiglottis cannot be seen Class I visualization of the soft palate, fauces, uvula, and both anterior and posterior pillars Class II visualization of the soft palate, fauces, and uvula Class III visualization of the soft palate and the base of the uvula Class IV soft palate is not visible at all

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

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

21

22 What alternative tools do we have?
To be familiar with all these tools

23 Airway Rescue Tools

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

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

26 Laryngoscopes

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

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

29 Bougie or Eschmann Stylette
Gum elastic – use as guidewire Advantages Gives definitive airway Easy to learn Inexpensive Can be used blindly Disadvantages Expertise requires practice Not recommended in “can’t intubate / can’t ventilate” scenario

30 Lighted Stylette Disadvantages Blind technique May damage airway
Usually requires darkened room Expertise requires practice Advantages Minimal neck movement Useful adjunct to laryngoscopy Portable and inexpensive Usable in bloody airway Provides definitive airway

31 Lighted Stylette Disadvantages Blind technique May damage airway
Usually requires darkened room Expertise requires practice

32 Combitube Airway Double lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tube Insert blindly à 90% esophageal Inflate proximal balloon: 100 mL Inflate distal balloon: 5 –15mL

33 Combitube Airway Double lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tube Insert blindly à 90% esophageal Inflate proximal balloon: 100 mL Inflate distal balloon: 5 –15mL

34 Pharyngeal-Tracheal Lumen Airway (PTL)

35 Laryngeal Mask Airway (LMA)

36 Laryngeal Mask Airway (LMA)

37 Laryngeal Mask Airway (LMA)

38 Laryngeal Mask Airway (LMA)
Test cuff before use Don’t lubricate anterior mask Insert only in comatose patient Keep cuff inflated until patient awake Don’t throw out!! Used 40 – 50 times

39 Laryngeal Mask Airway (LMA)
In elective patient who… …has not fasted …may have gastric contents …has fixed â lung compliance …is not profoundly unconscious …resists LMA airway insertion

40 Laryngeal-Tracheal Airway

41 Intubating LMA (iLMA) In elective patient who… …has not fasted
…may have gastric contents …has fixed â lung compliance …is not profoundly unconscious …resists LMA airway insertion

42 Intubating LMA (iLMA) In elective patient who… …has not fasted
…may have gastric contents …has fixed â lung compliance …is not profoundly unconscious …resists LMA airway insertion

43 Intubating LMA (iLMA)

44 Intubating LMA (iLMA)

45 Intubating LMA (iLMA)

46 Retrograde Tracheal Intubation

47 Retrograde Tracheal Intubation
Advantages Definitive airway Minimal neck movement Does not require full mouth open Disadvantages Takes time Requires skill Not recommended in cannot intubate / cannot ventilate

48 Flexible Fiberoptic Scope

49 Flexible Fiberoptic Scope
Disadvantages Expensive Expertise requires practice Delicate equipment needs careful maintenance Visual field easily impaired by blood and secretions

50 Rigid Fiberoptic Scope
Advantages Direct airway visualization Minimal neck movement May overcome difficult view Useful in disrupted airway Durable, sturdy instruments

51 Rigid Fiberoptic Scope
Bullard Wu Scope

52 Rigid Fiberoptic Scope
Upsher Levitan Scope Disadvantages Expensive Expertise requires practice Visual field easily impaired by blood and secretions Not readily available

53 Video Laryngoscope Glidescoe McGrath

54 Video Laryngoscope Glidescope

55 Video Laryngoscope

56 Video Laryngoscope LMA C-Trach

57 Surgical Airway: Cricothyroidotomy
Complications: Bleeding Infection Vocal cord damage Tracheal stenosis C/I <12yrs Laryngotracheal Disruption Coagulopathy

58 Surgical Airway: Cricothyroidotomy
Life-saving technique Surgical vs. needle / Seldinger vs. percutaneous kit You must know this procedure before starting rapid sequence

59 Surgical Airway: Cricothyroidotomy
Final common pathways for all cannot intubate / cannot ventilate scenarios “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen

60 Quicktrach Emergency Cricothyrotomy

61 Tran-Tracheal Jet Ventilation (TTJV)
Advantages Surgical airway of choice if 8 years or younger Effective Can serve as temporary airway before permanent airway Relatively simple procedure Disadvantages Significant complications if misplaced Need proper equipment Need high-pressure oxygen Does not protect against aspiration

62 TTJV

63 Awake Intubation Proper Preparation Drying Agent -EARLY
Appropriate Sedation Topical Anesthetic- Oral/Nasal Nerve Blocks Supplemental O2 / Monitor

64 Expired CO2 Confirmation

65 YELLOW = CO2 PURPLE = NO CO2

66 Difficult Airway Specific strategies:
Appreciate the importance of developing a primary and secondary approach Identify fundemental prenciples, as adapted from ASA Difficult Airway Algorithm Know 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 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 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 Position BURP

75 Plan B: Blind Techniques
BVM Bougi Videolaryngoscope LMA, iLMA Combitube Retrograde 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, Combitube Bougi, videolaryngoscope 3 Trantracheal Jet Ventilation? Retrograde intubation? 4 Cricothireotomy, Tracheostomy 1 alternative 2 3 4

78 Airway Rescue

79 Pearls of Airway Management
Be familiar with all airway rescue tools and techniques Recognize the difficult airway If you can’t intubate – Bag! If at first you don’t succeed, change something Don’t 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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