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THE DIFFICULT AIRWAY MANAGEMENT IN ADULT CRITICAL CARE 5 MAY 2014 J MATSHE.

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Presentation on theme: "THE DIFFICULT AIRWAY MANAGEMENT IN ADULT CRITICAL CARE 5 MAY 2014 J MATSHE."— Presentation transcript:

1 THE DIFFICULT AIRWAY MANAGEMENT IN ADULT CRITICAL CARE 5 MAY 2014 J MATSHE

2 AIRWAY MANAGEMENT  Obligatory & Necessary skill for ALLL Critical care practitioners  FAILURE to maintain airway & provide adequate oxygenation= ↑ patient morbidity & mortality; psychologically-distressing to attending registrar  ALL Critical Care patients-Initially viewed to have a potentially difficult airway & REMEMBER have less physiological reserves VS airway elective surgery

3 DEFINITION  DIFFICULT AIRWAY: Acc to ASA guidelines 2013=Clinical situation whereby conventionally trained anaesthetist experiences DIFFICULTY with either:  MASK VENTILATION or  TRACHEAL INTUBATION or  BOTH ( “CAN’T INTUBATE, CAN’T VENTILATE”) NB: AVOID AVOID AVOID!!!!!!!

4 DIFFICULT MASK VENTILATION  Unassited anaesthetist cannot maintain arterial oxygen saturation ≥90% by mask ventilation using 100% Oxygen & positive pressure OR  Cannot reverse signs of inadequate ventilation eg. Absence of chest movement & exhaled CO2 OR Presence of cyanosis

5 DIFFICULT LARYNGOSCOPY  Difficulty visualising any portion of vocal cords using a conventional laryngoscope: Cormack Lehane 3(epiglottis only)/4(soft palate only)

6 DIFFICULT ENDO-TRACHEAL INTUBATION  › 3 inserting ET tube Or  › 10 minutes to perform using conventional equipment

7 OUTLINE  INDICATIONS FOR INTUBATION  AIRWAY ASSESSMENT & PREDICTING DIFFICULT AIRWAY:  PRE-INTUBATION STRATEGY -Preparation -Pre-Oxygenation -Positioning -Premedication  PLANS & BACK UP PLANS  ADJUNCTS

8 INDICATIONS FOR INTUBATION  Inadequate Oxygenation  Inadequate Ventilation  Anticipate development of inadequate oxygenation/ventilation  Airway protection

9 PREDISPOSING FACTORS TO DIFFICULT INTUBATION  OPERATOR related: Unassisted junior trainee after-hours with no senior/specialist assistance  DISEASE related: All intubations EMERGENCIES  PATIENT related: EMERGENCY=Shortened preparation time;Recent previous intubation- predispose airway edema, subgottic inflammation & even stenosis & Operator Stress due to patient’s deteriorating condition

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11 AIRWAY ASSESSMENT History for airway assessment Potential Problems  Anaesthesia records All stages  Previous intubation trauma All stages  Previous surgery, radio-therapy to head/neck All stages  Airway disease process All stages  Systemic disease(rheum arthr, ankylos spondyl) Diff laryngoscopy  Sleep apnoea Loss of airway tone & Difficult laryngoscopy  Previous tracheostomy Difficult laryngoscopy and intubation  Gastro-oesophageal reflux Aspiration of gastric contents  Full stomach Aspiration of gastric contents

12 AIRWAY ASSESSMENT Exam for A A Potential Problems  Stridor All stages  Obesity Loss of airway tone and difficult laryngoscopy  Short neck Difficult laryngoscopy  ↓ mouth opening Difficult laryngoscopy  Receding jaw Difficult laryngoscopy  Hamster mouth Difficult laryngoscopy  Buck teeth Difficult laryngoscopy  Missing upper teeth Difficult laryngoscopy  Respiratory difficulty Difficult laryngoscopy  Neck masses All stages  Position of larynx/ trachea and availability of cricothryroid membrane Difficult laryngoscopy and intubation

13 BAG MASK VENTILATION

14  INTEGRAL component of Airway mx  If done correctly & successfully: Gives time to prepare for definitive airway mx  Entails 3 Principles: Patent Airway, Good mask seal & Proper ventilation

15 IDENTIFYING DIFFICULT BMV M O A N S  Mask seal: Can’t approximate mask  Obesity:Redundant tissues impede airflow  Age ›55yrs: Loss of tissue elasticity  No teeth:Mask doesn’t sit properly  Stiff lungs/body: ↑ pressure needed

16 HEAD TILT CHIN LIFT: 1 ST HAND DOWNWARD PRESSURE TOFOREHEAD ; 2 ND HAND INDEX & MIDDLE FINGERS LIFT CHIN OPENING AIRWAY MANOUVERE 1

17 JAW THRUST-UNSTABLE CERVICAL SPINE: PLACE HEELS OF HANDS ON PARIETO-OCCIPAL AREA & GRASP ANGLES OF MANDIBLE WITH FINGERS & DISPLACE JAW ANTERIORLY OPENING AIRWAY MANOUVRE 2

18 OROPHARYNGEAL: GUEDEL-SIZE CORRECTLY; INSERT-CURVE INVERTED, ROTATE 180˚ AS TIP REACHES POSTERIOR PHARYNX AVOID IN AWAKE PATIENT OPENING AIRWAY ADJUNCT 1

19 NASOPHARYNGEAL AIRWAY OPENING AIRWAY ADJUNCT 2

20 1 HAND: ALIGN PATIENT’S EXTERNAL AUDITORY MEATUS WITH STERNAL NOTCH USING E-C METHOD FOR MASK SEAL & BAG WITH OTHER HAND MASK VENTILATION TECHNIQUE 1

21 2 HANDED: 1 PERSON HOLDS MASK WITH BOTH HANDS USING E-C METHOD OR APPLY PRESSURE WITH THUMBS & LIFT JAW WITH FINGERS; 2 ND PERSON BAGS MASK VENTILATION TECHNIQUE 2

22 ENDOTRACHEAL INTUBATION

23 THE DIFFICULT INTUBATION Failure to intubate can result in severe adverse events such as:  Airway trauma  Aspiration  Hypoxemia/Anoxic brain injury  Hypotension  Cardiac arrest & Death BE PREPARED & HAVE A PLAN

24 IDENTIFYING THE DIFFICULT INTUBATION L E M O N  LOOK  EVALUATE  MALLAMPATI  OBSTRUCTION/OBESITY  NECK MOBILITY

25 DIFFICULT INTUBATION ASSESSMENT “LOOK”  Externally: Facial trauma; Unusual/Distorted anatomy  Internally: Foreign body; Secretions; Obstructing mass

26 DIFFICULT INTUBATION ASSESSMENT EVALUATE: RULE Mouth opening Tip of mentum to hyoid bone Thyromental distance Access to airway and obtaining glottic view Can tongue be deflected to accomdate laryngoscope Predicts location larynx to base of the tongue. If larynx high angles difficult

27 DIFFICULT INTUBATION ASSESSMENT

28 DIFFICULT AIRWAY ASSESSMENT OBESITY  Redundant tissues in upper airway may obscure glottis  Positioning imp: Pillows under shoulders OBSTBUCTION  Epiglottitis, Quisy

29 DIFFICULT AIRWAY ASSESSMENT NECK MOBILITY  ↓ Cervical spine mobility: RA,DM, Cervical immobility → COMPROMISED Sniffing position

30 PREPARATION PRE-OXYGENATION POSITIONING PREMEDICATION PRE-INTUBATION STRATEGY

31 PREPARATION  ASSESS AIRWAY: Look for signs of possible difficult bag mask ventilation/intubation OR both  ASSEMBLE EQUIPMENT: Check functional status  PREPARE MEDICATION  DEVELOP AIRWAY MANAGEMENT PLAN WITH BACK UP PLANS

32 PREPARATION S T O P  Suction  Tools(Laryngoscope)  Oxygen  Position/Plan M A I D  Monitors(Bp,Sats,Cap)  Ambu-bag,Airw devic  Iv access  Drugs

33 INFLUENCE OF LARYNGOSCOPES  Macintosh -No difference compared to Miller

34 LARYNGOSCOPES  Miller

35 LARYNGOSCOPES  McCoy -Has an angulated tip -Improves visualisation with less force; in neutral position

36 LARYNGOSCOPES  Bullard/Airtraq -Rigid fibre-optic laryngoscope -Alignment of axes not required

37 PREOXYGENATION  Establish oxygen reservoir -Replace nitrogenous room air mixture with 100% oxygen  Challenge in ICU -Head of bed elevation -NIPPV  Challenge in Obesity & Critically ill patients -Desaturate much quicker

38 POSITIONING  SUPINE -Access to airway obstructed  SNIFFING -Head elevated, Neck extended -Imaginary horizontal line from external auditory meatus to sternal notch -Access to airway improved

39 PREMEDICATION ICU pts-require very little or no drugs L O A D Lidocaine: Reactive airways & ↑ ICP Opioids: Blunt sympathetic response & ↑ BP Atropine: Bradycardia in kids particularly Defasciculating agent- ↓ dose competitive neuromuscular blockade: ↑ ICP

40 INDUCTION AGENTS  KETAMINE: Sedation & Analgesia; No hypotension; Bronchodilatory effect; Respiratory drive preserved; ↑ ICP & BP. Dose: 1-2mg/kg iv  PROPOFOL: Rapid onset; No analgesia; Hypotension. Dose: 1.5-3mg/kg iv  MIDAZOLAM: Time to effect › 15min ; Hypotension. Dose: mg/kg iv  ETOMIDATE: Rapid onset; No analgesia/Hypotension. Dose: 0.3mg/kg

41 MUSCLE RELAXANTS  Onset 45-60sec; DOA 6-10min.  Dose: 1-1.5mg/kg iv;  C/I-Rhabdomyolysis, Hyperkalemia, Burns › 72hrs & Hx Malignant HT  Onset 60min; Longer DOA than Sux.  Dose mg/kg iv SUXAMETHONIUMROCURONIUM

42 LARYNGOSCOPY TECHNIQUE

43 BIMANUAL LARYNGOSCOPY

44 CRICOID PRESSURE  Avoid regurgitation of gastric contents by occluding upper end of oesophagus  May worsen glottic view  BURP: Improve glottic view by manipulating thyroid cartilage

45 LARYNGOSCOPY

46 INSERTING ET TUBE

47 CONFIRM ET TUBE PLACEMENT

48 BOUGIE VIDEO LARYNGOSCOPE LMA CRICOTHYROID CANNULA SURGICAL CRICOTHYROIDOTOMY KIT AIRWAY ADJUNCTS

49 BOUGIE

50 VIDEO LARYNGOSCOPY

51 VIDEO LARYNGOSCOPES  GLIDESCOPE

52 VIDEO LARYNGOSCOPES  C-MAC

53 LMAs CLASSIC LMA INTUBATING LMA/FASTRACK

54 NEEDLE CRICOTHYROIDOTOMY

55 SURGICAL CRICOTHYROIDOTOMY

56 AND BACK UP PLANS..... THE PLAN

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59 REFERENCES  Critical care medicine.2008;36(7):  Anaesthesiology.2013;118:Practice guidelines for manangement of the difficult airway  Critical care and resuscitation.2003;5:43-52  Endotracheal intubation in ICU by Dr D Oxman 2013

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