1. Airway Management Techniques By Hwan Joo MD

2. Airway Presentation  Normal Airway Management  Closed Claims  Difficult Intubation and Tools  Difficult Ventilation and Tools  Intubation tools for Surgeons  Overall goals  Teach surgeons about airway tools  Not necessarily how to intubate

3. Indication for Tracheal Intubation  Oxygenation and Peep  Ventilation  Airway protection from Aspiration  Tracheal toilet and/lung washings  Route for drug administration

4. Airway Assessment  The Mallampati view may be indicative of difficult airway  Negative predictive value >99% for MP 1-2  PPV for MP 4 only 40%  MP and laryngeal view not very correlative

5. Difficult Airway Assessment  History of difficult Intubation  Physical examination  Trauma  C-spine precaution  Blood in airway  Airway trauma  Morbid obesity  RSI makes it worse!

6. Direct Laryngoscopy  3# Mcintosh blade most commonly used  No change in design for 60 years  High success rates in normal airways (99%)  However, difficult to learn  >50 uses to be proficient  Not so good with difficult airways

7. Laryngeal Mask Airway  Comes in sizes 3, 4, 5 (small, medium large)  Great for ventilation  Insertion easier if you have deep anesthesia  Does not protect against aspiration  Not able to deliver high pressure ventilation  Useful for difficult airways and failed laryngoscopy

8. Induction of for Intubation  Nothing  Patient already non-responsive  Medications contraindicated  Topical lidocaine  Midazolam, fentanyl  Etomidate±Sux  Ketamine±Sux  Propofol±Sux

9. Closed Claims - Caplan, Anesthesiology 1990  Airway -Largest and most costly form of injury (34% of all claims, $200,000+ US)  Inadequate ventilation (34%)  Esophageal intubation (18%)  Difficult intubation (17%)  36% of claims against difficult intubation cases considered preventable

10. Closed Claims in Canada  Between 1993-2003, 50% of all large CMPA suits in anesthesia were airway related  Average settlement was $500,000  75% of patients suffered brain damage or deaths  50% were associated with difficult airways  In half of these patients, difficult airway adjuncts were not used  Therefore, there is room for improvement

11. ASA Difficult Airway Algorithm  Recognized difficult airway  intubation vs non-intubation  facemask, LMA  regional  Unrecognized difficult airway  can ventilate  convert to spontaneous ventilation?  awake vs asleep  cannot ventilate  emergency measures required

12. Difficult Intubation -Ventilation Possible  Awaken patient  Asleep fiberoptic intubation  LMA without intubation  Intubation via LMA or ILMA  Lighted stylette  Combitube TM  Video laryngoscope

13. Flexible Fiberoptic Intubation  Awake fiberoptic intubation is the gold (Rose CJA 1994)  Asleep FOI, successful but,  It may be more difficult due to  Airway obstruction or apnea  Blood in pharynx  Limited time before oxygen desaturation  Should be done with help!

14. Laryngeal Mask Airway for intubation  Success for intubation with conventional LMA is variable (19-93%)  Success may be improved by the use of a pediatric bronchoscope via the ETT in LMA  LMA removal may be difficult after intubation  Consider LMA without intubation

15. Lighted Stylette (Trachlite TM )  With experience  Success rates reported to be up to 99% in patients with difficult airway (Hung, CJA 1995)  Success rates for novices 50% (Wilk, Resuc 1997)  Success rates decreased in patient with bull necks and obese patients

16. Combitube TM  Success rates by non- anesthesiologist with combitube has ranged (33- 93%)  Average beginner success rates expected to be in the 80-90% range (Anesthesia- trained)  May be associated with esophageal injuries and mediastinitis (Vezina, CJA 1998)

17. Video Laryngoscopes Glidescope  Rigid laryngoscope with CCD  View is very clear with no fogging  Blade angle 50-60 deg  Easy to use  Very rapid learning curve  Can also be learned by ER physicians, Surgeons

18. Glidescope in Use

19. Glidescope Success Rates with Experience Joo et al

20. Glidescope with Disposable Blade

21. McGrath Videolaryngoscope  Similar to Glidescope  Disposable blade cover  Beautiful all in one design  Optics not be as good  Narrow field of vision  More difficult?  More portable  More likely to disappear

22. Video Laryngoscopes RES-Q-SCOPE  LCD Screen  Disposable blade  Much cheaper initial cost  However, $50 per use

23. Airtraq What is wrong with this picture?

24. Ventilation Difficult or Impossible  Failed intubation is disturbing but…..  Failed ventilation is universally fatal!  Choices  LMA (will discuss ILMA later)  Combitube  Transtracheal airway  cricothryotomy  transtracheal jet ventilation  tracheostomy

25. Laryngeal Mask Airway  Success rates for ventilation as high as  95% after 1 attempt and 98% after 2 attempts  No decrease in success rates in patient’s with difficult airways  Overwhelming data of uses in difficult airways and in failed ventilation  may have saved 100’s of lives!  For IPPV use large LMA’s

26. What is the Best Device for Failed Ventilation? LMA vs. Combitube TM  Success is dependent on more on the operator’s experience than to tool  Majority of anesthesiologist have little or no experience with the Combitube  LMA should be the first choice for difficult ventilation scenarios  However, Combitube theoretically prevents aspiration

27. Trans Trachea Airway FOR UPPER AIRWAY OBSTRUCTION  TTJV (jet ventilation)  difficult with multiple complications  Needle cricothryotomy  High success rates using Seldinger technique  No need for jet  Slash or surgical tracheotomy  Messy but may do the job

28. Intubating Laryngeal Mask Airway (ILMA)

29. ILMA with FOB  Things of interest  Elbow connector  Continuous ventilation  PVC Tube  Metal rings in silicone tube not compatible with FOB  Better than C-Trach?  Better manipulation  Higher Success rates

31. What is this?  The view via ILMA is different from regular FOB  The epiglottis is often distorted  Obviously blind intubation failed  Larger ILMA required

32. LMA C Trach  ILMA with LCD screen  Improved success rates for intubation over ILMA  Success on normal airways about 90-95% based on limited studies  However, need greater mouth opening compared to ILMA, 2.5cm versus 2.0 cm  Same success rate for ventilation  Less trauma

34. Failed Intubation What to do as a Surgeon  Awaken patient if possible/feasible  Maintain ventilation and oxygenation  Facemask  LMA  Combitube  Call Anesthesia  Surgical Airway  Attempt ventilation throughout

35. Airway Tools not for Surgeons  FOB  Too much effort required to learn  Not good with secretions or blood  Not as useful in unplanned cases (ER)  Lighted Stylettes  Again, high learning curve  Not as useful in patients who are not paralyzed  High incidence of esophageal intubations

36. What is the Best Tool for Surgeons?  LCD Laryngoscopes are the way of the future  Currently, Glidescope is the easiest to use with the most literature supporting it  Must Practice on routine patients  Use it get familiarity  Bug the anesthesiologists to use it in the OR  Gold standard, Glidescope + FOB

37. Glidescope FOB Insertion

38. Glidescope FOB Intubation

39. The Future The future of intubation will be video assisted  In the past, intubators intubated in the dark by themselves  PRIVATE  (Like masturbation!)  The future will have everybody involved in the process of intubation  (ER Doc, Nurses, RT)  PARTY!  Everyone is involved

40. Final Recommendation  When faced with a difficult airway, stay on the beaten path of  Practice, Practice…  Use familiar but advanced devices  Do not persist with techniques that have failed  Secure ventilation

41. Practice in Simulation