1. Guidelines of difficult airway : what’s new ?
Olivier Langeron, MD, PhD
Department of Anesthesiology and Intensive Care
Pitié-Salpêtrière Hospital
Paris, France

2. Disclosures
BAXTER
COOK medical
COVIDIEN

3. Difficult airway management guidelines
SFAR difficult intubation : a collective expertise Ann Fr Anesth Réanim 1996, 2007 (2014)
ASA practice guidelines for management of the difficult airway Anesthesiology 1993, 2003, 2013
Canada the anticipated difficult airway with recommendations for management
Can J Anaesth 1998
UK difficult airway society guidelines for management of unanticipated difficult intubation Anaesthesia 2004

4. Difficult airway issues
Anticipate it, to manage it !
How ?
difficult airway risk factors
difficult airway algorithms

5. Definition of DMV S 1993 No universal definition
El-Orbany M and Woehlck HJ Anesth Analg 2009
1993
No universal definition
Simplification over time
2 main criteria despite lack of objectivity:
Difficulties to maintain oxygenation
Necessity of additional support to perform MV
2000
2003
2005
2006

6. Definition of difficult intubation (DI)
ASA : DI if conventionnal laryngoscopy > 3 attempts or > 10 minutes multiples attempts
SFAR 1996 : DI if conventionnal laryngoscopy > 2 attempts or > 10 minutes
and/or alternative technique required after optimization of head position, with or without external laryngeal maneuver
2013
2006

7. Anticipated DMV Impossible :
- lingual tonsill hyperplasia (LTH) Ovassapian A et al. Anesthesiology 2002
- increased risk after tracheal intubation failures (≥3) Mort T. Anesth Analg 2004
- laryngospasm / bronchospasm
Possible : prediction of DMV Langeron O et al. Anesthesiology 2000
Kheterpal S et al. Anesthesiology 2006

8. Hypertrophied Lingual Tonsil
From Jones DH et al. Anesth Analg 1993
Sagittal Section
of normal Tongue
and Larynx

9. Comparison of DMV prediction studies
Langeron 2000
Kheterpal 2006

10. DMV risk factors Increasing risk if at least 2 of these factors:
Increasing risk if at least 2 of these factors:
Age >55 yr
BMI >26kg/m2
Jaw protrusion severely limited
Lack of teeth
Snoring
Beard
X 4 risk of difficult intubation with a DMV

11. Definition of a difficult airway Laryngoscopy - Intubation
Mask ventilation 8
Cerebral damage
Death
easy
Interaction
impossible 8
Laryngoscopy - Intubation
DMV could be a dynamic process
Benumof JL Anesthesiology 1991

12. Multiple TI attempts

13. DMV prediction and number of risk factors
Kheterpal et al Anesthesiology 2006

14. DMV risk factor and clinical relevance
Johnson JO et al Anesthesiology 1999
Patient information +++
Ask to shave the beard ?

15. Optimization of mask ventilation
Better mask seal : appropriate face mask size, mask ventilation achieved by two persons with a two-handed mask ventilation technique
Use of large oral-pharyngeal / nasal-pharyngeal airways
One person assigned to O2 administration (flush valve…) and patient monitoring (SpO2 …)

16. DMV risk factor and clinical relevance
standard face mask ventilation
lower lip placement

17. DMV risk factor and clinical relevance
median value 0 ml (0–50ml) ml (365–485 ml)
Expired tidal volume (ml)
P <
standard face mask ventilation
lower lip placement

18. DI risk factors History of a DI ++++
History of a DI ++++
Recommended criteria (mandatory +++) :
Mallampati class >II
TMD <65mm
MO <35mm
Supplementary criteria
Limited jaw protrusion
Limited cervical spine mobility
Criteria dependent on context
BMI > 35kg/m2
OSA with neck circumference > 45.6cm
Neck and/or facial pathology
Pre-eclampsia

19. Strategy
Algorithms
Techniques

20. Strategy = Algorithms Oygenation maintenance
Altenative techniques to control the airway 20

21. Rationale to use algorithms
To Analyze the difficult airway situation
To elaborate (local) solutions
To broadcast information

22. 90 % ID solved with GEB
98 % patients intubated
100 % patients oxygenated

23. Oxygenation Maintenance
SFAR 2006
ANTICIPATED DIFFICULT INTUBATION
Strategic Options
2006
DMV prediction
Oxygenation Maintenance
( LMA or ILMA usable ? Invasive tracheal approach ? )
Choice of the anesthestic technique : apnea or spontaneaous ventilation ?

24. Spontaneous Ventilation
SFAR 2006
Anticipated
support
SFAR 2006
INTUBATION
Mask ventilation efficient
2006
Spontaneous Ventilation
Apnea possible
FAILURE
Laryngoscopy 2 trials –
Gum elastic bougie
FAILURE
ILMA
LMA <30 kg
Videoloaryngoscope
FIBERSCOPE
Recovery
Recovery
FAILURE
Recovery
Tracheal access
If impossible
Intubation
Intubation
Intubation
± fiberscope

25. OXYGENATION ILMA Others intubation techniques
Mask ventilation and/or intubation failures
= SUPPORT IN ANY CASES
2006
Intubation
ILMA
LMA <30 kg
Recovery
FAILURE Contre Indication
Transtracheal O2
Success
Failure
Others intubation techniques
CRICOTHYROIDOTOMY TRACHEOTOMY
FAILURE
Recovery
Recovery
Intubation

26. UNANTICIPATED DIFFICULT INTUBATION OXYGENATION ALGORITHM
= SUPPORT
and DI trolley
and Anesthesia maintenance +++
SFAR 2006
UNANTICIPATED DIFFICULT INTUBATION
2006
Mask Ventilation
inefficient
efficient
Laryngoscopy 2 trials -
Gum elastic bougie
ILMA
LMA <30 kg
Failure
Videoloaryngoscope
Ventilation ILMA
efficient
inefficient
INTUBATION ALGORITHM
OXYGENATION ALGORITHM
Intubation

27. ASA DIFFICULT AIRWAY ALGORITHM
Anesthesiology 1993 / 2003 /
Consider attempt LMA

28. ASA DIFFICULT AIRWAY ALGORITHM
Anesthesiology 2013
Videolaryngoscopes added

29. Algorithm Basic Rules
At each step : consider awaken patient option Never go a “bridge too far”, never try the “last” option
Algorithm fitting with the patient case, local means and operator abilities
Logistics (material, human resources and task organization) are mandatory

30. Strategy to manage a difficult airway : what remains !!!
Algorithm (ASA /SFAR) :
Mask ventilation adequate or not ?
Intubation algorithm or oxygenation algorithm
The good question
The good option

31. Basic airway management
Preoxygenation, SpO2 monitoring
Chin lift and Jaw thrust
Oral / nasopharyngeal airway devices
Limited tracheal intubation attempts (<3)

32. Conclusion
DMV prediction is mandatory (SFAR guidelines for ex), and the patient should be informed about the risk and the solutions to decrease it
The main goal of airway management is patient oxygenation and not necessary endotracheal intubation
A strategy (including DMV prediction and anesthesia techniques) arising from guidelines and algorithms is always the first step in a difficult airway management

33. DI
Oxygenation maintenance
DMV