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Presentation on theme: "DIFFICULT AIRWAY MANAGEMENT"— Presentation transcript:

Tools and Tactics for Success

2 First Case of the Day

3 ASA Definition The Difficult Airway- Difficult to Ventilate-
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

4 DISCUSSION 4th National Audit Project NAP4
Causes of difficult intubation Basic airway evaluation (Lemon Law ) Airway Management A-B-C Gallery of tools Extubation of the Difficult Airway ASA Difficult airway algorithm

5 Degrees of Airway Difficulty

6 Difficult Mask Ventilation
Overlap Difficult Mask Ventilation

7 Overlap Difficult Mask Ventilation Difficult SGA

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

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

10 4th National Audit Project NAP4
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 PRIMARY PROBLEMS Aspiration #1
Extubation Problems Tracheal Intubation Delayed Intubation Failed Intubation Can’t Intubate Can’t Ventilate

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

13 NAP4 Lessons Learned 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

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.

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

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

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
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
Look externally. Evaluate the rule. Mallampati. Obstruction? Neck 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

24 E-Evaluate the Rule 4/14/2017

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

26 Mallampati ?

27 Cormack & Lehane Grading

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

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

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

31 Thyromental Distance 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

Discussion with colleagues in advance Equipment tested before Senior help backup Definite initial plan (A) for ventilation and intubation Definite plan (B) than option of awake intubation Ideal situation surgery team standby

34 Preoxygenation Two Techniques Common in Use: Why Preoxygenate?
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


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

42 Video Laryngoscopy Airtraq McGrath C-Mac

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

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

46 Bullard Rigid Fiberoptic Laryngoscope
Time Experience Limited Maneuverability

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

First used in England Cheap Good in patients in whom only epiglottis is visualized

49 Supraglottic Airways SGA
Combitube LMA C

50 The Esophageal- Tracheal Combitube
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)

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

54 LMA C-Trach Ventilation Visualization Intubation

55 LMA-Proseal High seal pressure - up to 30 cm H20 - 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

56 LMA-Proseal

57 Fiberoptic Aided Intubation
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

59 Cricothyrotomy 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
Maxillofacial, Pharyngeal, or Laryngeal Trauma, Pathology or Deformity 16-Gauge or Larger (16g- tidal volume ) 15-30 psi with Insufflation 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

62 Retrograde Intubation

63 Extubation of the Difficult Airway

64 Airway Exchange Catheter
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

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

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

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

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

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

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

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

74 Two For The Road

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

76 Two For The Road

77 Questions?

78 Questions?


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