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 bothDifficult 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 intubationBasic airway evaluation (Lemon Law )Airway Management A-B-CGallery of toolsExtubation of the Difficult AirwayASA Difficult airway algorithm
9 An Emergent Surgical Airway is Not Always Assured Difficult Mask VentilationDifficult surgical airwayDifficultIntubationDanger Zone
10 4th National Audit Project NAP4 Sept 2008-Sept 2009 estimated 2,900,000 GA performed in the UKData collected on 114,904 GA’s from 309 hospitals over a 2 week period184 serious airway complications, including:-Death (14)-Brain Damage-Emergent Surgical Airway-Unexpected ICU admission
12 NAP4 Lessons LearnedPoor Airway Assessment & Poor Planning contributed to Poor OutcomesFailure to match strategy to assessment (technique)Failure to have prepared strategy (plan B and C)
13 NAP4 Lessons LearnedEmergency 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 LearnedAspiration was the single most common cause of death in anesthesia eventsImportantly most aspirations occur due to failure to recognize risk factors and failure to adjust the anesthetic technique accordinglyAspiration remains the most frequent cause of airway related deaths during anesthesia.
16 NAP4 Lessons LearnedOne third of the events occurred during emergence or in recovery. Obstruction was the common cause in these eventsRecommendations:Nasal TrumpetsOral AirwayAirway exchange catheterSGA prior to removal of ETT (Bailey Maneuver)Awaken patient with SGA in place
17 Predictors of Difficult Mask Ventilation BeardOSAObesityMale GenderMallampati class III or IVNeck Circumference
18 Predictors of Difficult Intubation Inadequate Preoperative Assessment.History of difficult intubationInadequate equipmentExperience not enough.Poor technique.Increased AgeMallampati 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 distanceLimited cervical range of motionSmall mouth openingTemporomandibular joint pathology
20 Basic Airway Evaluation in All Patients Previous anesthetic problemsGeneral appearance of the neck, face, maxilla and mandibleJaw movementsHead extension and movementsThe teeth and oropharynxThe soft tissues of the neckRecent 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 breastsProminent Upper Incisors (Buck Teeth)Receding Jaw (Dentures)BurnsFacial TraumaStridorMacroglossia (Lg Tongue)
23 E-Evaluate the 3-3-2 Rule 3 fingers fit in mouth 3 fingers fit from mentum to hyoid cartilage2 fingers fit from the floor of the mouth to the top of the thyroid cartilage
28 O-ObstructionBlood 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 teethGrade I --- > 35°Grade II – °Grade III – 12-21°Grade IV -- < 12°
31 Thyromental DistanceMeasure from upper edge of thyroid cartilage to chin with the head fully extended.A short thyromental distance equates with an anterior larynxGreater than 7 cm is usually a sign of an easy intubationLess than 6 cm is an indicator of a difficult airwayRelatively unreliable test unless combined with other tests
33 MANAGEMENT PLAN OF ANTICEPATED DIFFICULT AIRWAY Discussion with colleagues in advanceEquipment tested beforeSenior help backupDefinite initial plan (A) for ventilation and intubationDefinite plan (B) than option of awake intubationIdeal 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 AIf plan A fails-Go to plan BIf plan B fails-Go to plan C
36 Plan “A”: (ALTERNATE) Different Length of blade Different Type of BladeDifferent PositionDifferent Equipment
37 Plan “B”: (BVM and BLIND INTUBATION Techniques ) Mask VentilationBougieCombi-Tube?LMA an Option?Fiberoptic?
39 Failure.. Why does it happen No critical discussion with colleagues about proposed management planNo request for experienced helpExaggerated idea of personal abilityIll-conceived plan A and/or plan BPoorly executed plan A and/or plan BPersisting with plan A too long, starting the rescue plan too lateNot involving, and preparing, surgical colleagues
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 cordsRigid handle to facilitate one-handed insertion, removalEpiglottic elevating bar in the mask aperture which elevates the epiglottis as the ETT is passed throughAvailable in three sizes, one size for children, two sizes for adults
55 LMA-ProsealHigh seal pressure - up to 30 cm H20 - Providing a tighter seal against the glottic opening with no increase in mucosal pressureProvides more airway securityEnables use of PPV in those cases where it may be requiredA built-in drain tube designed to channel fluid away and permit gastric access for patients with GERD
59 Cricothyrotomy Airway established through the Cricothyroid Membrane Not a TracheostomyLarge Bore CatheterExpected skill of the AnesthetistContraindicated in Neonates and Children under age 6
60 Transtracheal Jet Ventilation Maxillofacial, Pharyngeal, or Laryngeal Trauma, Pathology or Deformity16-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 aspirationRetrograde wire is advanced until it emerges from the mouth. (Magill Forceps)Wire is Clamped/Secured at the entry siteETT advanced over the wire (Many Techniques)Wire removed leaving ETT in place
Your consent to our cookies if you continue to use this website.