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DIFFICULT AIRWAY MANAGEMENT Tools and Tactics for Success 1.

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Presentation on theme: "DIFFICULT AIRWAY MANAGEMENT Tools and Tactics for Success 1."— Presentation transcript:

1 DIFFICULT AIRWAY MANAGEMENT Tools and Tactics for Success 1

2 First Case of the Day 2

3 ASA Definition The Difficult Airway - is defined as the clinical situation in which a conventionally trained Anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both Difficult to Ventilate- is when signs of inadequate ventilation could not be reversed by mask ventilation or oxygen saturation could not be maintained above 90% Difficult to Intubate- is when a trained Anesthetist using conventional laryngoscope take’s more than 3 attempts


5 Degrees of Airway Difficulty 5

6 Overlap Difficult Mask Ventilation 6

7 Overlap Difficult Mask Ventilation 7 Difficult SGA

8 Triple Failure Difficult SGA 8 Difficult Mask Ventilation Difficult Intubation DANGER ZONE

9 An Emergent Surgical Airway is Not Always Assured Difficult Mask Ventilation 9 Difficult Intubation Difficult surgical airway Danger Zone

10 4 th National Audit Project NAP4 10 Sept 2008-Sept 2009 estimated 2,900,000 GA performed in the UK Data collected on 114,904 GA’s from 309 hospitals over a 2 week period 184 serious airway complications, including: -Death (14) -Brain Damage -Emergent Surgical Airway -Unexpected ICU admission

11 NAP4 Lessons Learned 11

12 NAP4 Lessons Learned Poor Airway Assessment & Poor Planning contributed to Poor Outcomes 1. Failure to match strategy to assessment (technique) 2. Failure to have prepared strategy (plan B and C) 12

13 NAP4 Lessons Learned 13 Emergency Percutaneous Cricothyrotomy failed 60% of the time

14 NAP4 Lessons Learned A common theme was “failure to plan for failure” In some cases when airway management was unexpectedly difficult the response was unstructured. In these cases outcomes were generally poor. The project identified numerous cases where awake fiber-optic intubation was indicated but not used 14

15 NAP4 Lessons Learned Aspiration was the single most common cause of death in anesthesia events Importantly most aspirations occur due to failure to recognize risk factors and failure to adjust the anesthetic technique accordingly Aspiration remains the most frequent cause of airway related deaths during anesthesia. 15

16 NAP4 Lessons Learned One third of the events occurred during emergence or in recovery. Obstruction was the common cause in these events Recommendations: Nasal Trumpets Oral Airway Airway exchange catheter SGA prior to removal of ETT (Bailey Maneuver) Awaken patient with SGA in place 16

17 Predictors of Difficult Mask Ventilation Beard OSA Obesity Male Gender Mallampati class III or IV Neck Circumference 17

18 Predictors of Difficult Intubation Inadequate Preoperative Assessment. History of difficult intubation Inadequate equipment Experience not enough. Poor technique. Increased Age Mallampati III or IV

19 Anatomical Factors Affecting Laryngoscopy Neck Circumference (Single Major Predictor in Obese) Short Neck. Protruding incisor teeth. Long high arched palate. Increase in either anterior depth or Posterior depth of the mandible decrease in Atlanto Occipital distance Limited cervical range of motion Small mouth opening Temporomandibular joint pathology

20 Basic Airway Evaluation in All Patients 20 Previous anesthetic problems General appearance of the neck, face, maxilla and mandible Jaw movements Head extension and movements The teeth and oropharynx The soft tissues of the neck Recent chest and cervical spine x-rays

21 Think L-E-M-O-N When Assessing a Difficult Airway L ook externally. E valuate the 3-3-2 rule. M allampati. O bstruction? N eck mobility.

22 L: Look Externally Obesity or very small. Short Muscular neck Large breasts Prominent Upper Incisors (Buck Teeth) Receding Jaw (Dentures) Burns Facial Trauma Stridor Macroglossia (Lg Tongue)

23 E-Evaluate the 3-3-2 Rule 3 fingers fit in mouth 3 fingers fit from mentum to hyoid cartilage 2 fingers fit from the floor of the mouth to the top of the thyroid cartilage 23

24 E-Evaluate the 3-3-2 Rule 5/6/2015 24

25 M- Mallampati classification Class-I Class-II Class-IIIClass-IV soft palate, fauces; Uvula, pillars. the soft palate, fauces and uvula soft palate and base of uvulaOnly hard palate

26 Mallampati ? 26

27 27 Cormack & Lehane Grading

28 O-Obstruction Blood Vomit Teeth Dentures Epiglottis Tumors Foreign Body (piercings) 28

29 N-Neck mobility -Measurement of Atlanto-Occipital Angle

30 Atlanto-Occipital Angle 30 Estimates the angle traversed by the occluded surface of the upper teeth Grade I --- > 35° Grade II –- 22-34° Grade III – 12-21° Grade IV -- < 12°

31 Thyromental Distance 31 Measure from upper edge of thyroid cartilage to chin with the head fully extended. A short thyromental distance equates with an anterior larynx Greater than 7 cm is usually a sign of an easy intubation Less than 6 cm is an indicator of a difficult airway Relatively unreliable test unless combined with other tests

32 Thyromental Distance 32

33 MANAGEMENT PLAN OF ANTICEPATED DIFFICULT AIRWAY 1. Discussion with colleagues in advance 2. Equipment tested before 3. Senior help backup 4. Definite initial plan (A) for ventilation and intubation 5. Definite plan (B) than option of awake intubation 6. Ideal situation surgery team standby

34 Preoxygenation Two Techniques Common in Use:  Tidal volume breathing (TVB) of 100% oxygen via a tight-fitting face mask for 5 minutes (Preferred Method)  Deep breaths/Vital Capacity 4 times within 0.5 min (Time to desaturation is consistently shorter then preferred method) Why Preoxygenate? O2 Consumption Vo2=250ml/min and 2500ml O2 in FRC (after preO2) = 10 minutes to use this O2

35 Airway Management A-B-C Start with Plan A If plan A fails- Go to plan B If plan B fails- Go to plan C

36 Plan “A”: (ALTERNATE) Different Length of blade Different Type of Blade Different Position Different Equipment

37 Plan “B”: (BVM and BLIND INTUBATION Techniques ) Mask Ventilation Bougie Combi-Tube? LMA an Option? Fiberoptic?

38 Plan-C Can’t Intubate.. Can’t Ventilate Needle Cricothyrotomy Transtracheal Jet Ventilation Retrograde Wire Intubation

39 Failure.. Why does it happen No critical discussion with colleagues about proposed management plan No request for experienced help Exaggerated idea of personal ability Ill-conceived plan A and/or plan B Poorly executed plan A and/or plan B Persisting with plan A too long, starting the rescue plan too late Not involving, and preparing, surgical colleagues 39


41 Rigid Laryngoscope Blades Of Alternate Design And Size 41 Macintosh Magill Miller Polio Mc Coy

42 42 Video Laryngoscopy Airtraq McGrath C-Mac

43 Video Laryngoscopy 43 VL Calls on a Alternative Skill Set In Critical Situations Unpracticed Techniques may not be Helpful

44 Video Laryngoscopy 44 Use a stylet and shape it to match your VL Blade Watch the patient not the monitor when inserting the VL Blade Trouble passing tube -Withdraw -Lift Less -Drop your angle

45 Video Laryngoscopy Versus Direct Laryngoscopy 45 Improved Glottic View Experienced vs Inexperienced Cost Standard of the future? Picture Confirmation?

46 Bullard Rigid Fiberoptic Laryngoscope 46 Time Experience Limited Maneuverability

47 Stylet Devices 47 Lighted Stylet Optical Stylet No Nasal Intubation No Suction Limited to above Cords

48 48 GUM ELASTIC BOUGIE (GEB) –First used in England –Cheap –Good in patients in whom only epiglottis is visualized

49 Supraglottic Airways SGA 49 Combitube LMA

50 The Esophageal- Tracheal Combitube 50 Useful as emergency airway Two lumens allow function whether place in esophagus or trachea Esophageal balloon minimizes aspiration

51 Laryngeal Mask Airway

52 VARIATIONS OF LMA LMA – Classic (standard) LMA – Flexible (reinforced) LMA – Unique (disposable LMA) LMA – Fastrach (intubating LMA) LMA – C-Trach (Visualization/Intubation) LMA – Proseal (gastric LMA) 52

53 LMA – Fastrach (Intubating LMA) Rigid, anatomically curved, airway tube that is wide enough to accept an 8.0 mm cuffed ETT and is short enough to ensure passage of the ETT cuff beyond the vocal cords Rigid handle to facilitate one- handed insertion, removal Epiglottic elevating bar in the mask aperture which elevates the epiglottis as the ETT is passed through Available in three sizes, one size for children, two sizes for adults 53

54 LMA C-Trach Ventilation Visualization Intubation 54

55 LMA-Proseal High seal pressure - up to 30 cm H 2 0 - Providing a tighter seal against the glottic opening with no increase in mucosal pressure Provides more airway security Enables use of PPV in those cases where it may be required A built-in drain tube designed to channel fluid away and permit gastric access for patients with GERD 55

56 LMA-Proseal 56

57 Fiberoptic Aided Intubation 57 Most Versatile Tool Available for Difficult Intubation Optical Elements are Small Visualization Below the Cords Awake Intubation Unique Skillset Lens Contamination Cost

58 Can’t Ventilate/Cant Intubate 58

59 Cricothyrotomy 59 Airway established through the Cricothyroid Membrane Not a Tracheostomy Large Bore Catheter Expected skill of the Anesthetist Contraindicated in Neonates and Children under age 6

60 Transtracheal Jet Ventilation 60 Maxillofacial, Pharyngeal, or Laryngeal Trauma, Pathology or Deformity 16-Gauge or Larger (16g- tidal volume 400-700) 15-30 psi with Insufflation 1- 1.5 sec. Specialized systems capable of using Low- pressure O2

61 Retrograde Intubation Local Anesthesia of the airway, skin wheel at puncture site. Cricothyrotomy performed with air aspiration Retrograde wire is advanced until it emerges from the mouth. (Magill Forceps) Wire is Clamped/Secured at the entry site ETT advanced over the wire (Many Techniques) Wire removed leaving ETT in place 61

62 Retrograde Intubation 62

63 Extubation of the Difficult Airway 63

64 Airway Exchange Catheter 64 Extubation in a controlled manner with a AEC Well tolerated Airway can be reintubated Can deliver Oxygen Provides an avenue for suction

65 Airway Exchange Catheter Localize the airway through existing ETT Mark AEC at required depth (tube depth +3 CM) Insert AEC and remove ETT Tape AEC in place Assess for removal of AEC 65

66 Bailey Maneuver 66 Exchange of ETT for a LMA Decreased Severity of Cough Maximum change SBP Maximum change HR Sore throat

67 Bailey Maneuver 67 Patient is Deep Oral-pharyngeal suction Deflated LMA placed behind ETT LMA cuff inflated ETT cuff deflated and removed LMA used for ventilation

68 68 2003 2013 What's New in the ASA Difficult Airway Algorithm

69 69 What's New in the ASA Difficult Airway Algorithm Assess Likelihood and Impact section. Added: Difficult Supraglottic airway placement Separated: Intubation and Laryngoscopy

70 70 2003 2013 What's New in the ASA Difficult Airway Algorithm Basic Management Choices: Video-assisted Laryngoscopy as initial approach to Intubation

71 71 2003 2013 What's New in the ASA Difficult Airway Algorithm “LMA” changed to “SGA”

72 72 2003 2013 What's New in the ASA Difficult Airway Algorithm Video-Assisted Laryngoscopy: Listed first under Alternative Difficult Intubation Approach

73 73 2003 2013 What's New in the ASA Difficult Airway Algorithm Under Invasive Airway Access: Percutaneous airway techniques and jet ventilation remain but are de-emphasized

74 Two For The Road 74

75 Two For The Road Be familiar with alternative intubating techniques and use them on a regular basis in your day to day practice. 75

76 Two For The Road 76

77 Questions? 77

78 Questions? 78

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