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Moderator – Prof Anjan Trikha Presenter - Priya

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1 Moderator – Prof Anjan Trikha Presenter - Priya www.anaesthesia.co.in anaesthesia.co.in@gmail.com

2  Krishna  25years/male  Student  Resident of Delhi

3  Pain and difficulty in chewing × 1 week  Restriction of mouth opening ×1 week

4 History of present illness :  H/O fall from tree one week back  Following which patient developed Pain and swelling on left side of jaw Pain on opening mouth Difficulty in chewing food  No H/O loss of consciousness  No H/O oral, nasal or ear bleed

5 Past history  No H/O any previous GA exposure  No H/O asthma, TB,DM & any drug allergy Personal history :  Non smoker Treatment history :  Inter maxillary wiring was done after trauma Family history :  Not significant

6  Alert, conscious &oriented  No pallor, icterus, clubbing, cyanosis, edema and lymphadenopathy Vitals  PR- 70 beats/min all peripheral pulses palpable  BP – 124/78mm Hg R, upper arm, supine  Weight – 58 kg

7  Inter incisor gap – wiring present  Length of upper incisor -<1.5 cm  No buck teeth or loose teeth  MMP class – could not be assessed  Upper lip bite – unable to do because of wiring  Thyromental distance = 6.5 cm  Sub mandibular compliance - normal

8 Neck movements  Flexion - adequate  Extension - adequate  Neck thickness normal  No short neck  Nasal patency – equally patent, no deviation or growth seen

9  B/L vesicular breath sounds present  No adventitial sounds Cardiovascular system :  First and second heart sound heard, no murmur present

10  Higher mental functions normal  No sensory and motor weakness Abdomen :  No visible swelling  No organomegaly

11  Hb – 12gm%  Platelets – 2 lakhs/mm3  TLC – 8400/mm3  Na/K – 140/4.2meq/l  Urea/creatinine – 20/0.9mg/dl  LFT - WNL

12  OPG X-ray – fracture in ramus of mandible left side with inter maxillary fixation (IMF) in situ

13  Fracture mandible left ramus with reduced mouth opening posted for open reduction and internal fixation

14 Open reduction and internal fixation of mandible fracture with plating

15  25 year old male with left mandibular fracture with interdental wiring in situ posted for open reduction and internal fixation

16  Nasal intubation laryngoscopy guided after removal of wiring

17  Nasal intubation – its inherent risks  Sharing of airway  Access to airway  Extubation issues  PONV prophylaxis  Post operative airway obstruction

18  Inform about procedure & risk  Written consent  Premedication aspiration prophylaxis- oral ranitidine antisialogogue – Glycopyrrolate i.m nasal decongestant – xylometazoline drops  Pre op fasting  Wiring was removed on the day of surgery

19  Check machine and emergency equipments  Standard monitoring – ECG, NIBP, pulse oximetry,capnography  iv access secured – extension tubing  Nasal prepration with xylometazoline drops  Softening of nasal tube  Preoxygenation for three minutes

20  Sniffing position  Induction – fent 2mcg/kg, propofol 2- 3mg/kg  Mask ventilation assessed ->Vecuronium – 0.1mg/kg  Lubricated 7.5 size nasal RAE tube introduced through rt nostril  Tube guided into glottis under laryngoscopy  Equal air entry confirmed

21  Eye padding, oral packing done  Positioning for surgery  Maintainence – oxygen, air and isoflurane, vecuronium, fentanyl  Antiemetics – dexamethasone and ondensetron  Monitor airway pressure

22  Reversal – neostigmine and glycopyrrolate  Removal of pack and thorough suctioning  Extubation – fully awake, adequate tidal volume, following commands  Postoperative-  Oxygen by face mask  Pulse oximetry  Beware of vomiting aspiration

23  RAE (nasal) tube, naso pharyngeal airways, warm saline, magill forceps & LA jelly  Fibreoptic bronchoscopy, suction apparatus  Lidocaine preprations- 2% viscous,2% injectable solution,10 or 15% spray,4% topical solution  Eye pads, throat pack, small pillows & rolls  Intravenous accesses secured

24  Fibreoptic guided intubation after i.v induction,paralysis& IPPV awake with sedation  Blind nasal intubation- awake post induction and paralysis  Light wand guided  Retrograde intubation  tracheostomy

25  A clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation or both

26  It is not possible for unassisted anaesthesiologist to maintain the SpO 2 > 90% using 100% O 2 and positive pressure mask ventilation in a patient whose SpO 2 was > 90% before or  It is not possible for the unassisted anaesthesiologist to prevent or reverse signs of inadequate ventilation during mask ventilation

27 Difficult laryngoscopy  It is not possibe to see any portion of the vocal cords after multiple attempts at conventional laryngoscopy Difficult tracheal intubation  A clinical situation in which intubation requires more than three attempts or ten minutes using conventional laryngoscopic techniques

28  Performance by a reasonably experienced laryngoscopist  The use of the optimal sniffing position  The use of OELM  One change in length/type of blade

29  History  Specific tests for assessment ◦ Difficult mask ventilation ◦ Difficult laryngoscopy ◦ Difficult surgical airway access  Radiologic / photographic assessment

30  Congenital difficult airways  Acquired ◦ Rheumatoid arthritis, Acromegaly, tumors of tongue, larynx  Iatrogenic ◦ radiotherapy, Laryngeal/tracheal/TMJ surgery  Reported previous anaesthetic problems ◦ Database

31  Inter-incisor gap : >3cm  Buck teeth +  Length of incisor: <1.5cm  Upper lip Bite  MMP class  Palate: arching / narrowing  TMD: >6cm  Mandibular compliance  Neck length: sufficient  Neck diameter: thin or thick  Neck movement

32  Mouth opening  Evaluation of tongue size relative to pharynx  Mandibular space  Mobility of the joints ◦ TMJ ◦ Neck mobility

33  With maximal mouth opening  Acceptable value > 4 cm  Positive results: Easy insertion of a 3 cm deep flange of the laryngoscope blade < 3 cm: difficult laryngoscopy < 2 cm: difficult LMA insertion  Affected by TMJ and upper cervical spine mobility

34 Samsoon-Young’s modification of Mallampati Test  Patient in sitting position  Maximal mouth opening in neutral position  Maximal tongue protrusion without arching  No phonation

35  Class III or IV: signifies that the angle between the base of tongue and laryngeal inlet is more acute and not conducive for easy laryngoscopy  Limitations ◦ Poor interobserver reliability ◦ Limited accuracy

36 73%19% 8%

37 MMP class Cormack and Lehane grade Grade 1Grade 2Grade 3Grade 4 Class I (73%)59%14%-- Class II (19%)5.7%6.7%4.7%1.9% Class III & IV (8%) -0.5%5%2.5% Airway Management, Jonathan Benumof

38 Thyromental distance (Patil test)  Distance from the tip of thyroid cartilage to the tip of mandible  Neck fully extended  Minimal acceptable value – 6.5 cmSignificance  Negative result – the larynx is reasonably anterior to the base of tongue  Very low sensitivity-20%

39 Modification to improve the accuracy  Ratio of height to thyromental distance (RHTMD)  Useful bedside screening test  RHTMD < 25 or 23.5 – very sensitive predictor of difficult laryngoscopy Sternomental Distance (Savva Test)  >12.5cm

40  Patient is asked to hold the head erect, facing directly to the front  maximal head extension  angle traversed by the occlusal surface of upper teeth  Grade I:> 35°  Grade II:22-34°  Grade III:12-21°  Grade IV:< 12°

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42  Placing one finger on the patient’s chin  One finger on the occipital protuberanceResult  Finger on chin higher than one on occiput  normal cervical spine mobility  Level fingers  moderate limitation  Finger on the chin lower than the second  severe limitation  Angle traversed by the vertex or forehead > 90° from max flexion to max extension is a specific +ve test for atlanto-occipital joint.

43  Class A: able to protrude the lower incisors anterior to the upper incisors  Class B: lower incisors just reach the margin of upper incisors  Class C: lower incisors cannot reach the margin of upper incisorsSignificance  Class B and C: difficult laryngoscopy

44  Class I: Lower incisors can bite the upper lip above vermilion line  Class II: can bite the upper lip below vermilion line  Class III: can not bite the upper lip Less inter- observer variability

45  Age > 55 years  BMI > 26 kg/m 2  History of snoring  Beard  Edentulous

46 Difficult LMA Insertion  Mouth opening < 2 cm  Intraoral/pharyngeal masses (e.g. lingual tonsils) Difficult Direct Tracheal Access  Gross obesity  Goitre  Deviated trachea  Previous radiotherapy  Surgical collar

47 Diagnostic test MMP TMD Sternomental distance Mouth opening Wilson score MMP+TMD Sensitivity 49% 20% 62% 22% 46% 56% Specificity 86% 94% 82% 97% 89% 97%

48 Wilson Score  5 factors ◦ Weight, upper cervical spine mobility, jaw movement, receding mandible, buck teeth  Each factor: score 0-2  Total score > 2  predicts 75% of difficult intubations

49 Difficult mask ventilation  Mask fit  Obesity  Age  No teeth  Snoar

50 Difficult laryngoscopy  Look  Evaluate…3.3.2  Mallampati  Obstruction  Neck movement

51 L-Look externally (facial trauma, large incisors, beard, large tongue) E-Evaluate 3-3-2 rule 3- inter incisor gap 3- hyomental distance 2- hyoid to thyroid distance M-MMP score O-Obstruction (epiglottitis, quinsy) N-Neck mobility Ron and Walls’ Emergency Airway Management

52 Difficult EGD insertion  Restricted mouth opening  Obstruction of upper airway  Disrupted/distorted anatomy  Stiff lungs/cervical spine

53 Difficult cricothyrotomy  Surgery  Hematoma  Obese  Radiation / burn  Tumor

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56  Patent airway  Spontaneous breath  Larynx-No anterior displacement  Aspiration-protection  Neck movement-minimal  Neurological monitoring

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58  H/o difficult intubation & Predicted difficult airway May be considered in the following situations (usually with a coexisting difficult airway):  High risk of aspiration  Hemodynamically very unstable  Respiratory failure

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60  Patient refusal  Uncooperative 1.child 2. mentally retarded 3. intoxicated 4. combative  Allergic to all LA

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62  Need for alternative intubation  Difficult, time consuming but safer  Slightly uncomfortable but pain-free  Injections required for better tolerance  Recall ±  LA complications rarely  Experienced physician-extra safety measures  Pt may opt for conventional - last resort

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64  BZD…Midazolam 20-40mcg/kg i.v bolus  Opioid…fentanyl 0.5-2.0mcg/kg i.v bolus remifentanil 0.05-0.5mcg/kg/min  Ketamine…0.2-0.5mg/kg i.v  Propofol…0.25mg/kg i.v bolus 50-100mcg/kg/min infusion  Dexmedetomidine…1mcg/kg i.v followed by 0.2-0.7mcg/kg/hr  Inhalations…Sevo / Des …pediatric DA

65  Adequate fasting  H 2 blocker  Metoclopramide  Sodium citrate Anti-sialogogue Anti-sialogogue  Atropine 10-20mcg/kg i.v or i.m  Glycopyrollate 5-10mcg/kg i.v or i.m  Scopolamine 0.3-0.6mg i.v or i.m or s.c

66  0.025% to 0.05% oxymetazoline nasal drops in each nostril; once before shifting from ward & once in holding area.  4% cocaine + 2% lidocaine + 1% phenylephrine

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68  Staff to assist  Monitors : ECG, BP, EtCO2, SpO2  Supplemental oxygen  Airway equipments-Difficult airway cart  Surgeon ready for tracheostomy 1. Pt in extremes 2. Airway catastrophy

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71  Flexible fibrescope guided  Blind nasotracheal  Rigid fibrescope guided  Trachlight / light wand guided  ILMA guided  Other SGA guided  Retrograde intubation  Direct laryngoscopy

72  Supine sniffing position  Guided by breath sound or capnography  Lubricated tube  Patent nare  Gently advance

73 Five response positions: Position T (Trachea): Goal position! Breath sound +; tube advances, patient coughs Position A (Anterior): breath sounds+; the tube stops, and the patient coughs Response A:withdrawal and re-advance; neck gradually flexed Position L or R (Left or Right pyriform sinus): breath sounds STOP, unable to advance tube, NO coughing; tube may be palpable on one side of the neck. Response L or R: slight withdrawal till breath sounds resume; slow rotation of head to opposite side and re- advance.

74  Position E (Esophagus): Breath sounds STOP, tube advances, NO coughing.  Response E: withdrawing until breath sounds resume and then : 1. Extend patient's head and re-advance. 2. Largely inflate cuff, advance tube until resistance is felt, maintain some advancing pressure on tube while cuff is slowly deflated. 3. Apply posterior pressure on the larynx and re-advance tube. 4. Leave one ETT inside esophagus to block it and insert another ETT to intubate the trachea.

75  Beck Airway Airflow Monitor(BAAM)- (Tracheal Whistle) disposable device that magnifies the patients respirations with a whistle sound.  Bougie guided blind intubation  NG tube guided blind intubation

76  Explicit descriptions of DA ◦ Difficult face mask ventilation ◦ Difficult laryngoscopy ◦ Difficult tracheal intubation ◦ Failed intubation  Purpose- facilitate mx. of DA, ↓adverse outcomes  Focus on anaesthesia care  All locations, all ages

77  Basic preparation ◦ Inform ◦ Ascertain help ◦ Preoxygenation ◦ Supplemental oxygenation throughout Portable storage unit  Rigid laryngoscope blades  ETTs  ETT guides  LMAs  FFOI equips  RI  Em NI a/w vent  Em invasive a/w  Exhaled CO2 detector

78  Strategy depending on ◦ Anticipated surgery ◦ Patient condition ◦ Skill & preference of anaesthesiologist  4 basic problems  3 basic management choices  Primary approach  Alternative approach  Exhaled CO2 to confirm tracheal intubation

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81  Strategy for extubation of DA ◦ Awake? ◦ Adverse impacts on ventilation ◦ Further A/w management plan ◦ Guide for reintubation  Follow up

82  Open ended, wide choice of techniques  Emphasis on prediction of difficult airway  No stratification of available a/w devices  No expression of strength of recommendation

83  Management of un-anticipated difficult intubation in an adult non-obstetric patient  Paediatric, obstetric patients & patients with upper a/w obstruction excluded  Flow charts based on series of plans  Careful planning with backup plans  Maintenance of oxygenation takes priority  Seek the best assistance available

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86 Complete explanation of the reason for performing the airway nerve blocks, is essential Consider (a) an alternative plan, i.e the direct spray of LA or spray with a nebulizer (b) the time available (c) the patient's condition Use of appropriate sedation to maintain patient comfort These techniques should be practiced in nonemergency situations so that when their success is required for a difficult intubation they can be performed appropriately

87  Topical ◦ Spray ◦ Jel ◦ Injection ◦ nebulization  Nerve blocks individual multiple

88 PreparationDose Injectable/topical solution1%, 2%,4% Viscous solution1%, 2% Ointment2%,5% Aerosol10%

89 Amount of LA absorbed varies Systemic absorption of topically applied lidocaine is limited 5 mcg/ ml, toxic limit of blood lidocaine Chinn and colleagues found plasma lidocaine levels of 0.44 μg/mL after inhalation of 400 mg of nebulized lidocaine Baughman and associates found that patients breathing 4 mg/kg aerosolized lidocaine developed plasma levels of less than 0.5 μg/mL Oral lidocaine produced even lower plasma levels because much of the dose is swallowed & subjected to first-pass metabolism by the liver Swallowed lidocaine in the setting of topical airway anesthesia can cause nausea and vomiting

90 Lidocaine applied directly to the trachea and bronchi results in higher plasma levels Viegas and Stoelting found plasma levels of 1.7 μg/mL 9 minutes after tracheal installation of 2 mg/kg lidocaine Sutherland and Williams in their study found that despite a total dose of lidocaine (5.3 ± 2.1 mg/kg), the mean peak arterial plasma lidocaine concentration was low (0.6 ± 2.1 μg/mL) Gargling of large volumes (0.3 mL/kg) of 2% lidocaine may be associated with peak lidocaine concentrations approaching a potentially toxic level

91  Total dose of lidocaine should be limited to 8.2 mg/kg in adult pts  Take extra care in elderly & pts with liver, cardiac impairment  Minimum amount of lidocaine necessary should be used when installed through FOB Thorax 2001;56 (suppl 1)

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93 Anterior ethmoidal nerveAnterior 2/3 of nasal septum Lateral wall of nose Sphenopalatine NPosteroir 1/3 of septum Floor of nose Glossopharyngeal NPosterior 1/3 of tongue Posterior & lateral pharyngeal wall Anteror surface of epiglottis Internal br of superior laryngeal NLarynx includ. Vocal cords Recurrent laryngeal NBelow the level of vocal cords trahea

94  Plethora of sensory fibers  Multiple origins  Topical application – the best and safe  Nerve blocks Sphenopalatine N Anterior ethmoidal N

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98  Vagus, facial, glossopharyngeal N  Topical anaesthesia sufficient in majority  Gag reflex difficult to suppress by topical alone

99  Deep,sub mucosal pressure receptors  Postrerior 1/3 of tongue  Gag happens more on oral intubation  Glossopharyngeal nerve (GPN) – the afferent arc

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103  The use of a tongue blade facilitated by application of a topical LA to mouth  If air is aspirated, needle needs to be withdrawn  If blood is aspirated, it is arterial (carotid artery), the needle is too posterior and too lateral. It needs to be redirected medially

104  Topical spray Atomiser Spray as you go Transcricoid injection Nebulized lidocaine  Superior laryngeal nerve block

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106  External approach ◦ Cornu of hyoid ◦ Cornu of thyriod ◦ Thyroid notch Internal approach piriform fossa

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109 Caution not to insert the needle into the thyroid cartilage, injection of LA into vocal cords cause edema If air is aspirated, the needie pierced laryngeal mucosa & to be retrieved If blood is aspirated (superior laryngeal artery or vein), needle to be redirected more anteriorly For evaluation of vocal cord movement, only the internal laryngeal nerve needs to be blocked For awake intubation, SLN and RLN need to be blocked

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112  Translaryngeal injection  Spray as you go  Labat’s technique

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116 Pt needs to be informed that the injection of LA solution make him or her cough Contraindicated in patients with unstable neck During the block, pt should not talk, swallow, or cough Catheter left in place until the intubation is completed for injecting more LA if necessary& to decrease the likelihood of subcutaneous emphysema

117  Non invasive  Useful in pts at risk of aspiration  Injecting LA through suction port of FOB  Wait 30- 60 sec before advancing to deeper structure and repeat the maneuver  Two methods oxygen spray technique Catheter technique

118  Attach three-way stopcock to suction port  Connect oxygen tubing with flow@2-4 l /min  Through other port of 3 way inject LA  Advantages high Fio2 delivery clean lens disperse mucous away aids innabulizing LA

119  Pass a angiographic or epidural catheter into suction port of FOB  Till it project 5 mm beyond FOB lens  Inject LA through proximal connection  Allows accurate placement of LA

120  Safe, non invasive technique  Useful in pts with unstable neck, ↑IOP &ICP  Needs pt’s cooperation  5ml of 4% lidocaine @oxygen flow of 6L/min, ultrosonic nebulizer over 10- 15 min period  O2 flow < 6L/min yields droplet size of 30- 60 microns

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137 www.anaesthesia.co.in anaesthesia.co.in@gmail.com


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