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Difficult tracheal intubation

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Presentation on theme: "Difficult tracheal intubation"— Presentation transcript:

1 Difficult tracheal intubation
Dr Tuan Pham Duc 06/2010

2 Plan Preintubation checklist. Intubation kit .
RSI ( Rapid sequence intubation ) Predicting difficult tracheal intubation Bougie ( Eschmann stylet ) . Laryngeal mask airway-Fastrach ( Intubating LMA) Cricothyroidotomy Alternatives intubation techniques Confirmation of ETT placement . Miscellaneous Summary

3 Preintubation checklist

4 Intubation kit Laryngoscope ET Stylet Syringe 10ml Suction catheter
Carbon dioxide detector Oral & nasal airways Ambu bag & mask attached to oxygen source

5 Rapid sequence intubation
Endotracheal intubation using RSI is the cornerstone of emergency airway management . RSI: the administration of a potent induction agent followed immediately by a rapidly neuromuscular blocking agent to induce unconsciousness & motor paralysis for tracheal intubation

6 RSI 3 phases: pretreatment-induction-paralysis.
Pretreatment : LOAD Lidocaine Opiod analgesics Atropine Defasciculating agents

7 Pretreatment medications

8 Induction medications

9 Paralytic medications

10 Predicting difficult tracheal intubation
LEMON rule Look externally E Evaluate the rule Mallampati scale Obstruction present ? Neck mobility

11 Difficult airway assessement
Look externally : physical features such as a small mandible , large tongue , short bull neck & obesity , facial or mandibular fracture are all red flags for a difficult airway


13 Difficult airway assessement
Mallampati classification

14 Difficult airway assessement
Obstruction : 3 signs of upper airway obstruction are stridor , muffled voice,difficulty swallowing secretions. Neck mobility:cervical spine immobilization in trauma , medical condition such as ankylosing spondylitis or RA.

15 McCormack & Lehane grade

16 Bougie ( Eschmann stylet )

17 Bougie ( Eschmann stylet )
It can be beneficial in the following situations : Grade 3 view Poor grade 2 view As a general intubation aid

18 A bougie can be used on the 1st attempt intubation when DL has failed to yield an adequate view

19 LMA A laryngeal mask airway


21 LMA

22 Fastrach( Intubating LMA)

23 Intubating LMA sizes 1 (<5kg) 1,5 (10-20kg ) 2,4 ( 20-50kg )

24 Cricothyroidotomy Insertion of a tracheal tube through an incision in the cricothyroid membrane .

25 Alternatives intubation techniques
Glottiscope ( Airtraq..) Special laryngoscopes Lighted stylet intubation Fiberoptic techniques. Esophageal-tracheal Combitube Retrograde intubation

26 Airtraq

27 Combitube

28 Confirmation of ETT placement
Chest auscultation: bilateral breath sounds Detection of CO2 exhaled. Chest Xray :

29 A- Capnography B-C CO2 color change indicator

30 Miscellanous Cricoid pressure:Sellick’s maneuver
External Laryngeal Manipulation or BURP Backward Upward Right Pressure maneuver ELM improved the laryngoscopic view by one whole grade in most pts initially rated 2 or 3 All pts presenting grade 3 view were converted to grade 1 or 2 with ELM

31 Summary Always be prepared for a difficult airway.
No single airway assessment tool is sufficiently sensitive nor specific to reliably predict or rule out a difficult airway. In many cases features of the patient’s morphology & pathology enable prediction of a difficult airway

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