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EMCOP airway management1 Airway management in morbid obese patients J P Mulier MD PhD Sint Jan Brugge-Oostende Bariatric center of Excellence www.publicationslist.org/jan.mulier.

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Presentation on theme: "EMCOP airway management1 Airway management in morbid obese patients J P Mulier MD PhD Sint Jan Brugge-Oostende Bariatric center of Excellence www.publicationslist.org/jan.mulier."— Presentation transcript:

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2 EMCOP airway management1 Airway management in morbid obese patients J P Mulier MD PhD Sint Jan Brugge-Oostende Bariatric center of Excellence

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4 3 Is mask ventilation safe in morbid obese patients? Intra abdominal pressure correlates with BMI Intra abdominal pressure correlates with BMI J P Mulier EJA 2009 J P Mulier EJA 2009 Abnormal reflux scores correlates with BMI Abnormal reflux scores correlates with BMI Fisher B. Dig Dis Sci Fisher B. Dig Dis Sci During abdominal compression, the rate of LES pressure increase is faster than that of the gastric pressure, suggesting an active contraction at the esophagogastric junction During abdominal compression, the rate of LES pressure increase is faster than that of the gastric pressure, suggesting an active contraction at the esophagogastric junction R Mittal Am J Physiol Gastrointest Liver Physiol 1990 R Mittal Am J Physiol Gastrointest Liver Physiol 1990

5 EMCOP airway management 4 BMI effect on abdominal P/V relation J Mulier ISPUB 2009 J Mulier ISPUB 2009 Pressure volume relation is linear Pressure volume relation is linear PV0 and E define each patient PV0 and E define each patient J Mulier IFSO 2007 J Mulier IFSO 2007

6 EMCOP airway management 5 Is mask ventilation safe in morbid obese patients? A deLeon Body position and esophageal sphincter pressures in obese patients during anesthesia Acta Anesth Scand 2010

7 EMCOP airway management 6 Mask ventilation Rapid sequence induction? Awake intubation? Safe to ventilate by mask? Safe to ventilate by mask? Yes No …Never if Yes No …Never if High intra abdominal pressures PV0 up 12 High intra abdominal pressures PV0 up 12 But LES prevents regurgitation … But LES prevents regurgitation … High mask pressures needed High mask pressures needed Volutrauma risk post intubation Volutrauma risk post intubation CPAP by mask before induction CPAP by mask before induction non-invasive CPAP: the SUPER-Boussignac non-invasive CPAP: the SUPER-Boussignac

8 EMCOP airway management 7 Is Sellick maneuver usefull? Displacement of esophagus Displacement of esophagus Lowering of LES = less protection? Lowering of LES = less protection?

9 EMCOP airway management 8 Original Sellick maneuver Hypoharynx and not esophagus is compressed! Hypoharynx and not esophagus is compressed!

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11 10 Help position: head elevated laryngoscopy position J. Brodsky: obese patients: difficult in mask ventilation J. Brodsky: obese patients: difficult in mask ventilation No difference in difficult intubation if properly positioned. No difference in difficult intubation if properly positioned. Brodsky, J. B. et al. Anesth Analg 2003;96: a J. Brodsky A morbidly obese patient will be in position for direct laryngoscopy when an imaginary horizontal line can be drawn from the sternal notch to the external auditory meatus

12 EMCOP airway management 11 Copyright restrictions apply. Intubation is not difficult if… difficult mask ventilation = difficult intubation Proper positioning (help) normalizes the risk of difficult intubation. ( Brodsky) Proper positioning (help) normalizes the risk of difficult intubation. ( Brodsky) Trachea pharyngeal alignment by Trachea pharyngeal alignment by Head pillow Head pillow Thorax elevation Thorax elevation Use of an inflatable pillow, safety bird is simple and effective to rotate thoracic column. Use of an inflatable pillow, safety bird is simple and effective to rotate thoracic column. Video laryngoscopy must be available Video laryngoscopy must be available

13 EMCOP airway management 12 Video laryngoscopy

14 EMCOP airway management 13 intubation

15 EMCOP airway management 14 Sterno mental distance without safety bird Sterno mental distance Normal position Use of inflatable pillow Mulier J.P., Dillemans B. Intubation time with and without inflatable intubation device Eur J Anesthesia 2007 Suppl

16 EMCOP airway management 15 Effect of safety bird Trachea – pharyngeal angle Trachea – pharyngeal angle > 30° 30°< 30° No safety birdwith safety bird No safety birdwith safety bird Mulier J.P., Dillemans B. CT analysis of the safety bird in mobid obese patients Obes Surg :444

17 EMCOP airway management 16 Intubation Prediction of difficult intubation Prediction of difficult intubation Not BMI or obesity Not BMI or obesity based on neck circumference > 50 cm based on neck circumference > 50 cm Good Positioning is important Good Positioning is important Risk not higher if properly positioned Risk not higher if properly positioned Help position (J Brodsky) Help position (J Brodsky) Safety bird (JPMulier) Safety bird (JPMulier) Awake Bronchoscopic intubation? Awake Bronchoscopic intubation? Not needed anymore? Not needed anymore? Video laryngoscopy must be available Video laryngoscopy must be available

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20 EMCOP airway management 19 Knowledge test among Anesthesiologist & Intensivists Hyperinflation of the cuff can lead to… Courtesy S Blot et al. 2009

21 EMCOP airway management 20 Knowledge test Cuff pressure is determined most accurately by means of... Courtesy S Blot et al. 2009

22 EMCOP airway management 21 Practice test Cuff pressure is controlled by Courtesy S Blot et al Finger palpation Finger palpation Manometer control every 8 hours Manometer control every 8 hours Continous monitored and automatic adapted Continous monitored and automatic adapted Most often in anesthesia Most often at intensive care Minority of intensive care units

23 EMCOP airway management 22 Microaspiration: also with perfect cuff pressure Migration of supraglottic material past the ETT cuff into the respiratory tract. Pictured: inadvertent microaspiration of contrast media after a barium swallow examination in an intubated patient Reproduced from Macrae et al. Br Med J (Clin Res Ed);283:1220 with permission from BMJ Publishing Group Ltd.

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25 EMCOP airway management 24 A B C Runs througwghstop on top runs & stop In vitro tests

26 EMCOP airway management 25 Taperguard is a good indication in bariatric surgery to prevent silent aspiration Bronchoscopic evaluation in morbid obese patients ventilated at > 5 cm H20 peep No leak

27 EMCOP airway management 26 SOS: Complications measured in 1164 surgery patients Postoperative complications:13 % pulmonary complications6.1 % other complications4.8 leakage, abscess2.1 wound complications1.8 thrombosis, embolism0.8 bleeding 0.5 Complications required reoperation in 2.2 % of the patients. Reoperations and conversions over 10 years: Banding31 % VBG21 Gastric bypass17 Sjostrom Sjostrom N Engl J Med 2007

28 EMCOP airway management 27 Per-operative silent aspiration Normal cuffs leak! Normal cuffs leak! Peep is not protecting Peep is not protecting To do: Gel, microcuff or taperguard cuff Gel, microcuff or taperguard cuff Gel not 100% protection Gel not 100% protection Cuff pressure monitoring and stabilisation at 30 cmH20 Cuff pressure monitoring and stabilisation at 30 cmH20 Subglottic suctioning Subglottic suctioning

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31 EMCOP airway management 30 Ventilation Peep Peep never interrupt, keep minimum 5 cmH2O never interrupt, keep minimum 5 cmH2O PCV vs VCV PCV vs VCV PCV risk for volutrauma PCV risk for volutrauma No outcome difference No outcome difference PCV only when high airway pressures? PCV only when high airway pressures? Only when low saturation? Only when low saturation? Beach chair and abdominal model Beach chair and abdominal model Improves total thoraco pulmonary compliance Improves total thoraco pulmonary compliance Permissive hypercapnia Permissive hypercapnia

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33 EMCOP airway management 32 Hypercapnia Permissive hypercapnia? Permissive hypercapnia? et CO2 is higher in morbid obese patients et CO2 is higher in morbid obese patients Increases cardiac output Increases cardiac output Less wound infections Less wound infections Increases blood pressure Increases blood pressure Prevent post operative bleeding Prevent post operative bleeding Pressure support easier or needed? Pressure support easier or needed? Breathing against ventilator possible Breathing against ventilator possible Contra indication: pulmonary hypertension Contra indication: pulmonary hypertension

34 EMCOP airway management 33 Can anesthesiology help to prevent post op bleeding? Yes 110/57 145/78 J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric bypass surgery. Obes Surg 2007; 17: 1051

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36 EMCOP airway management 35 PSV is possible even with full muscle relaxation Diaphragm remains active, enough to trigger ventilator at 0,6 L/min sensitivity Diaphragm remains active, enough to trigger ventilator at 0,6 L/min sensitivity Extra dose of Morfine stops PSV indicating no auto trigger phenomen Extra dose of Morfine stops PSV indicating no auto trigger phenomen PROFOUND MUSCLE RELAXATION DOES NOT DISTURB PRESSURE SUPPORT VENTILATION. Mulier J, Blacoe D PGA 2009

37 EMCOP airway management 36 PSV allows pain therapy optimalisation Before after extra sufentanil bolus

38 EMCOP airway management 37 Weaning with PSV Stimulates own breathing Stimulates own breathing Possible during muscle relaxation Possible during muscle relaxation Maximum morfine loading possible Maximum morfine loading possible Continue peep and cpap in spont breathing Continue peep and cpap in spont breathing Never hypoventilation and hypoxia Never hypoventilation and hypoxia Allow rise in et CO2, Allow rise in et CO2, less muscle relaxation needed at the end less muscle relaxation needed at the end Not breathing against ventilator Not breathing against ventilator Not disturbing laparoscopic workspace and view Not disturbing laparoscopic workspace and view

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40 EMCOP airway management 39 Post op gastric tube aspiration test Empty stomach pouch to prevent aspiration Empty stomach pouch to prevent aspiration Treat if new red blood is detected Treat if new red blood is detected

41 EMCOP airway management 40 Extubation Aspiration before extubation is important Aspiration before extubation is important Oral cavity Oral cavity Prevent post extub aspiration Prevent post extub aspiration Gastric pouch Gastric pouch Detect intraluminal bleeding Detect intraluminal bleeding Prevent nausea, vomiting Prevent nausea, vomiting Supra glottis Supra glottis Ctu ? Prevent silent aspiration Ctu ? Prevent silent aspiration Extubation during aspiration risk of atelectasis Extubation during aspiration risk of atelectasis better under positive airway pressure better under positive airway pressure

42 EMCOP airway management 41 OSA OHS OSA obstructive sleep apnea OSA obstructive sleep apnea OHS obesity hypoventilation syndrome OHS obesity hypoventilation syndrome See lecture tomorrow See lecture tomorrow

43 EMCOP airway management 42 President Jan P Mulier Vice-President Yigal Leykin Secretary Luc De baerdemaeker Treasurer Nick Kennedy Become member ESPCOP

44 EMCOP airway management 43 Second ESPCOP Scientific meeting Multidisciplinarity Pordenone, Italy 18 sept 2010


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