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Airway Management Carl W. Peters, M.D. Clinical Associate Professor of Anesthesiology Division of Critical care Medicine Department of Anesthesiology University.

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Presentation on theme: "Airway Management Carl W. Peters, M.D. Clinical Associate Professor of Anesthesiology Division of Critical care Medicine Department of Anesthesiology University."— Presentation transcript:

1 Airway Management Carl W. Peters, M.D. Clinical Associate Professor of Anesthesiology Division of Critical care Medicine Department of Anesthesiology University of Florida College of Medicine

2 Outline Etiology of respiratory failure Trauma airway as Difficult Airway by default Quick Evaluation and Prediction of the airway Airway Pharmacology Management strategy Old gadgets and new gadgets Confirming endotracheal intubation

3 ED ICUs Floor Special Diagnostic Stations Inter-facility Transport Hypoxia Hypercarbia Intolerable WOB Current / imminent inability to protect airway –Neurological Impairment –Hemodynamic Instability –Cardiac Arrest Special Diagnostics Difficult Airways are Everywhere... WHY?WHERE?

4 Don’t Forget... You are NOT in the Operating Room… Patients –Sicker –Unknown Fewer Resources –People –Equipment –Time

5 Hospital Location % Patients Complications P-value, risk ratio (95% CI) Surgical ICU (32 beds) Medical ICU (16 beds) Floor Neurosurgical / trauma (10 beds) ED Coronary ICU (12 beds) Radiology / cardiac catheterizations / PACU BradycardiaRegurgitationAspirationHypoxemiaHypercarbia < 0.04, 1.5 ( ) < 0.004, 1.9 ( ) < 0.002, 3 ( ) < 0.03, 0.6 (.43-93) < 0.001, 1.7 ( ) ICU = intensive care unit, PACU = postanesthesia care unit, % patients are for the entire database. Complication rate / RR / CI compared to other areas studied. Mort T A&A 2004;99: Frequently Complicated

6 Primary Disease Category %Patients 2 or fewer attempts (%) > 2 attempts (%) All groups combined Cardiac (CHF, MI, arrhythmia) Pulmonary (pneumonia, aspiration, COPD, secretions) Sepsis-SIRS (pulmonary, abdominal, misc.) Neurosurgical/neurological (CVA, seizure, trauma) Trauma Metabolic (DKA, Renal or liver failure, OD) GI bleeding MI = myocardial infarction; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; Misc = miscellaneous; CVA = cerebral vascular event; DKA = diabetic ketoacidosis; GI = gastrointestinal; SIRS = systemic inflammatory response syndrome; OD = overdose *P < 0.03 when compared with sepsis and cardiac groups *13.9* * Mort T A&A 2004;99: May be more difficult than usual

7 Difficult Airway: Definition is Not Uniform in Among Different Countries Difficult Intubation : > 3 attempts to intubate in 10 minutes Difficult Intubation > 1 attempt with the same blade or a change in blade or adjunct to DL; Use of alternative devices / techniques when intubation has failed. ASA CSA

8 Schwartz DE et al. Anesthesiology 1995;82:367 Death as a Complications of Emergency Airway Management in Critically Ill Adults: A Prospective Investigation of 297 Tracheal Intubations 10 month study 238 adult ICU patients / 297 consecutive translaryngeal tracheal intubations Mortality: 3% during or within 30 minutes of intubation Difficult Intubation: > 2 attempts at intubation.  8% intubations Sometimes Lethal…

9 Levitan RM Ann Em Med 2004; 44: Overall intubation success, patient conditions permitting physiognomic airway assessments, and rapid sequence intubation failures. Data from the ED Total Intubations Non- Cardiac Arrest Not Following Simple Commands* C-Spine Immobilized Not Following Simple Commands and C-Spine Immobilized Following Simple Commands and No C-Spine Precautions Failed RSI (all RSI = 838)* Total (%, 95% CI) † (53, 50-57) (43, 40-47) (25, 22-28) (32, 29-35) C-spine, Cervical spine; RSI, rapid sequence intubation. *A GCS motor score of <6 or specific medical record documentation (“not following commands”) was used to define this †Twelve non-cardiac arrest patients were intubated without RSI (nasal, 8; laryngoscopy but with induction agents only, 4); 838 patients underwent RSI, of whom 597 were trauma patients and 241 were medical patients.

10 Outline Clinical characteristics of the patients Quick Evaluation and Prediction Airway Pharmacology: Outback management Management strategy Old gadgets and new gadgets Confirming endotracheal intubation

11 Br. J Anesth. 1988, 61,

12 60% VERY EASY7% VERY DIFFICULT 6% VERY DIFFICULT

13 X-treme Mallampati: 0 Tiberin Anesth Analg 93(4) 1073: 2001 Xie T Anesth Analg 2001 (93) 1073

14 X-treme Mallampati: 4

15 Outline Airway Pharmacology Management strategy Old gadgets and new gadgets Confirming endotracheal intubation

16 DRUGDOSEONSETOFFSETT 1/2  T 1/2  Induction Propofol1-2 mg/kg sec5-10 min2-2.3 m29-44 m Infusion mcg/kg/min Etomidate mg/kg< 60 sec5 min2.7 m3 + 1 hr Ketamine1-3 mg/kg< 60 sec10-15 min17 min3 hr Infusion0.5-3 mg/kg/hr79 m Midazolam mg/kg30-60 sec6-15 m6-15 m1.7-4 hr Infusion0.5-1 mcg/kg/min Thiopental1-4 mg/kg30-60 sec10-15 m5-8 m5-17 hr Induction Agents and Trauma Hypovolemia Myocardial Depression? Increased ICP

17 NMB Agents for RSI and Trauma DRUGDOSEONSETOFFSET Succinylcholine1-1.5 mg/kg30-60 sec5-10 min Benzylisoquinolinium NMBs Mivacurium0.3 mg/kg90 sec19-60 min Cisatracurium0.4 mg/kg60-90 sec min Atracurium0.6 mg/kg60-90 sec min Aminosteroid NMBs Rocuronium0.3 mg/kg60-90 sec25-30 min Vecuronium0.3 mg/kg60-90 sec> 120 min …or None 1 mg / Kg lean body weight Sux ED 95 is 0.25 mg / Kg

18 Sux outside the OR… Gerich TG et al J Trauma Aug 45(2):312-4 ER Docs OR Docs % Complications % Success

19 Emergency Medicine Anesthesia Total intubations Nasal intubation (no DL tried) Total DL Attempted Total DL attempts unknown Total DL attempts known Successful intubation by DL Intubated on first DL, no. (%) Intubated on second DL, No. (%) Intubated > 3, No. (%) [95% CI]* Cricothyrotomy (ie, failed DL † ), No. (%) (86.4%) 50 (11.0) 12 (2.6) [ ] 2 (0.4) (89.7%) 13 (6.7) 7 (3.6) [ ] 0 † The Beauty or the Beast? Levitan RM, Ann Emerg Med, 2004;43:48-53 * NS between ED Physicians and Anesthesiologists

20 Alternative Intubation and Ventilation Devices in 95 US Academic ER Programs Levitan RM Ann Emerg Med 1999 Jun;33:694-8

21 The Art of Ventilation …Your first back-up method

22 Pre-oxygenation

23 Sellick maneuver –Patient supine, head in neutral or slightly extended (sniffing) position; –Cricoid cartilage pushed dorsally with thumb and forefinger to occlude the esophagus; Compressing it against anterior portion of C6; Maneuver prevents the passive regurgitation; Allows for BVM ventilation “without worry” of stomach distention. Sellick BA, Lancet, 1961;2:404

24 = 1 Kg Vanner R Anaesthesia : 1-3

25 The Difficult Airway Algorythm: A Simple Strategic Approach 1 2 3

26 Fiberoptic Intubation F-A-S-T Nasal better tolerated (if not contraindicated) –head trauma –coagulopathy Expect more secretions/blood; use glycopyrrolate 0.2 mg IV if you have time Prepare the nasopharynx with phenylephrine spray, nasal trumpets/lubricants, ready with esmolol/NTG boluses Premedicate with aerosol 4% lidocaine 10 mL (+ racemic epinephrine/ glycopyrrolate)

27 Predictable Difficult Airway due to Recognized Difficult Airway: New Fiberoptic Gadgets 3.1, 4.1 and 5.2 mm diameter

28 IF the Patient is Unconscious: Manual in-Axis Neck Stabilization

29 Nasal Intubation Patient breathing spontaneously No obvious coagulopathy or nasopharyngeal trauma No basal skull fracture Small tube Lubrication Nasal vasoconstrictors

30

31

32 La Forte Fx…

33 Just be CAREFUL!

34 The Difficult Airway in the ED : A Simple Strategic Approach Lack of cooperation Rapid deterioration Who Decides When and How ?

35 Section 2 Unpredictable Difficult Airway with Ability to Ventilate By Mask

36 Section 2: Unpredictable Difficult Airway with Ability to Ventilate By Mask

37

38 LMA-ProSeal ProSeal

39 ILMA as a Conduit to Endotracheal Intubation

40 Esophageal/Tracheal Double Lumen Airway (Combitube) (Combitube) 41Fr (Adults over 5 feet) 37 Fr (Adults from 4 feet to 5 feet)

41 Esophageal/Tracheal Double Lumen Airway (Combitube) Advantages –Prehospital Cardiac Arrest –Unconscious C-spine Injury Patient –Combat Situations –Obese or Pregnant Patients Contraindications and Disadvantages –Hypopharyngeal pathology –Esophageal tumors or varices –High incidence of pharyngeal mucosa tear –Common failure to ventilate –COST

42 SUPRAGLOTTIC OBSTRUCTION

43

44 Inability to Ventilate or Oxygenate Section 3: Inability to Ventilate or Oxygenate

45 Emergency Cricothyroidotomy anatomy Anatomy schematic Inf. thyroid vein Thyroid gland Cricothyroid arteries

46

47 Melker Emergency Crycothyrotomy Set

48 don’t try this your first time on a patient !!!! (practice airway drills)

49 Use Simulation Where Available

50 Use the OR for Relaxed and Focused Bedside Teaching/Practice

51 Practice Algorithms

52 Practice in the Animal Lab

53 Practice with cadavers

54 Needle Cricothyrotomy Concept Wadhwa 9F 6cm Arndt 9F 6cm Patil 6 an 9 F, 6 cm No name reinforced 6 F,5 and 7.5 cm

55 Downregulate the Pressure !!! 50 psi

56 Emergency Tracheostomy…

57 Confirmation of Airway Placement Visualization of the vocal cords Breath sounds Fogging of the tube ET CO2 –Colorimetric –Capnographic Esophageal detection devices

58 Colorimetric ET CO 2

59 ALIVE (and well) intubated in the wrong place or….. DEAD

60 Confirmation of Airway Placement During Cardiac Arrest Falk J.L. Prehospital emergency care 1999;3:

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