Airway management in morbid obese patients J P Mulier MD PhD 1150 1850 1947 1977 2010 Airway management in morbid obese patients J P Mulier MD PhD Sint Jan Brugge-Oostende Bariatric center of Excellence www.publicationslist.org/jan.mulier EMCOP airway management

EMCOP airway management

Is mask ventilation safe in morbid obese patients? Intra abdominal pressure correlates with BMI J P Mulier EJA 2009 Abnormal reflux scores correlates with BMI Fisher B. Dig Dis Sci. 1999 During abdominal compression, the rate of LES pressure increase is faster than that of the gastric pressure, suggesting an active contraction at the esophagogastric junction R Mittal Am J Physiol Gastrointest Liver Physiol 1990 EMCOP airway management

BMI effect on abdominal P/V relation J Mulier ISPUB 2009 Pressure volume relation is linear PV0 and E define each patient J Mulier IFSO 2007 EMCOP airway management

Is mask ventilation safe in morbid obese patients? A deLeon Body position and esophageal sphincter pressures in obese patients during anesthesia Acta Anesth Scand 2010 EMCOP airway management

Mask ventilation Safe to ventilate by mask? High mask pressures needed Rapid sequence induction? Awake intubation? Safe to ventilate by mask? Yes <-> No …Never if High intra abdominal pressures PV0 up 12 But LES prevents regurgitation … High mask pressures needed Volutrauma risk post intubation CPAP by mask before induction non-invasive CPAP: the SUPER-Boussignac EMCOP airway management

Is Sellick maneuver usefull? Displacement of esophagus Lowering of LES = less protection? EMCOP airway management

Original Sellick maneuver Hypoharynx and not esophagus is compressed! EMCOP airway management

EMCOP airway management

Help position: head elevated laryngoscopy position J. Brodsky: obese patients: difficult in mask ventilation No difference in difficult intubation if properly positioned. Brodsky, J. B. et al. Anesth Analg 2003;96:1841-1842-a J. Brodsky A morbidly obese patient will be in position for direct laryngoscopy when an imaginary horizontal line can be drawn from the sternal notch to the external auditory meatus EMCOP airway management

EMCOP airway management Intubation is not difficult if… difficult mask ventilation = difficult intubation Proper positioning (help) normalizes the risk of difficult intubation. ( Brodsky) Trachea pharyngeal alignment by Head pillow Thorax elevation Use of an inflatable pillow, safety bird is simple and effective to rotate thoracic column. Video laryngoscopy must be available EMCOP airway management Copyright restrictions apply.

EMCOP airway management Video laryngoscopy EMCOP airway management

EMCOP airway management intubation EMCOP airway management

Sterno mental distance without safety bird Normal position Use of inflatable pillow Mulier J.P., Dillemans B. Intubation time with and without inflatable intubation device Eur J Anesthesia 2007 Suppl EMCOP airway management

Effect of safety bird Trachea – pharyngeal angle > 30° < 30° > 30° < 30° No safety bird with safety bird Mulier J.P., Dillemans B. CT analysis of the safety bird in mobid obese patients Obes Surg 2008 18:444 EMCOP airway management

EMCOP airway management Intubation Prediction of difficult intubation Not BMI or obesity based on neck circumference > 50 cm Good Positioning is important Risk not higher if properly positioned Help position (J Brodsky) Safety bird (JPMulier) Awake Bronchoscopic intubation? Not needed anymore? Video laryngoscopy must be available EMCOP airway management

EMCOP airway management

EMCOP airway management

EMCOP airway management Knowledge test among Anesthesiologist & Intensivists Hyperinflation of the cuff can lead to… Courtesy S Blot et al. 2009 EMCOP airway management 19

EMCOP airway management Knowledge test Cuff pressure is determined most accurately by means of... Courtesy S Blot et al. 2009 EMCOP airway management 20

Practice test Cuff pressure is controlled by Finger palpation Manometer control every 8 hours Continous monitored and automatic adapted Most often in anesthesia Most often at intensive care Minority of intensive care units Courtesy S Blot et al. 2009 EMCOP airway management 21

Microaspiration: also with perfect cuff pressure Migration of supraglottic material past the ETT cuff into the respiratory tract. Pictured: inadvertent microaspiration of contrast media after a barium swallow examination in an intubated patient Microaspiration is the leakage of secretions and foreign material past the cuff. The visual is of an intubated patient after a barium swallow. The contrast media is evident in the left bronchi, which leads us to conclude that microaspiration past the endotracheal tube cuff occurred. Reproduced from Macrae et al. Br Med J. 1981 (Clin Res Ed);283:1220 with permission from BMJ Publishing Group Ltd. EMCOP airway management

EMCOP airway management

EMCOP airway management In vitro tests A B C Runs througwgh stop on top runs & stop EMCOP airway management

EMCOP airway management Taperguard is a good indication in bariatric surgery to prevent silent aspiration Bronchoscopic evaluation in morbid obese patients ventilated at > 5 cm H20 peep No leak EMCOP airway management

SOS: Complications measured in 1164 surgery patients Postoperative complications: 13 % pulmonary complications 6.1 % other complications 4.8 leakage, abscess 2.1 wound complications 1.8 thrombosis, embolism 0.8 bleeding 0.5 Complications required reoperation in 2.2 % of the patients. Reoperations and conversions over 10 years: Banding 31 % VBG 21 Gastric bypass 17 Sjostrom N Engl J Med 2007 EMCOP airway management

Per-operative silent aspiration Normal cuffs leak! Peep is not protecting To do: Gel, microcuff or taperguard cuff Gel not 100% protection Cuff pressure monitoring and stabilisation at 30 cmH20 Subglottic suctioning EMCOP airway management

EMCOP airway management

EMCOP airway management

EMCOP airway management Ventilation Peep never interrupt, keep minimum 5 cmH2O PCV vs VCV PCV risk for volutrauma No outcome difference PCV only when high airway pressures? Only when low saturation? Beach chair and abdominal model Improves total thoraco pulmonary compliance Permissive hypercapnia EMCOP airway management

EMCOP airway management

EMCOP airway management Hypercapnia Permissive hypercapnia? et CO2 is higher in morbid obese patients Increases cardiac output Less wound infections Increases blood pressure Prevent post operative bleeding Pressure support easier or needed? Breathing against ventilator possible Contra indication: pulmonary hypertension EMCOP airway management

Can anesthesiology help to prevent post op bleeding? Yes 110/57 145/78 J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric bypass surgery. Obes Surg 2007; 17: 1051 EMCOP airway management

EMCOP airway management

PSV is possible even with full muscle relaxation Diaphragm remains active, enough to trigger ventilator at 0,6 L/min sensitivity Extra dose of Morfine stops PSV indicating no auto trigger phenomen PROFOUND MUSCLE RELAXATION DOES NOT DISTURB PRESSURE SUPPORT VENTILATION. Mulier J, Blacoe D PGA 2009 EMCOP airway management

PSV allows pain therapy optimalisation Before after extra sufentanil bolus EMCOP airway management

EMCOP airway management Weaning with PSV Stimulates own breathing Possible during muscle relaxation Maximum morfine loading possible Continue peep and cpap in spont breathing Never hypoventilation and hypoxia Allow rise in et CO2, less muscle relaxation needed at the end Not breathing against ventilator Not disturbing laparoscopic workspace and view EMCOP airway management

EMCOP airway management

Post op gastric tube aspiration test Empty stomach pouch to prevent aspiration Treat if new red blood is detected EMCOP airway management

EMCOP airway management Extubation Aspiration before extubation is important Oral cavity Prevent post extub aspiration Gastric pouch Detect intraluminal bleeding Prevent nausea, vomiting Supra glottis Ctu ? Prevent silent aspiration Extubation during aspiration risk of atelectasis better under positive airway pressure EMCOP airway management

EMCOP airway management OSA OHS OSA obstructive sleep apnea OHS obesity hypoventilation syndrome See lecture tomorrow EMCOP airway management

EMCOP airway management Become member ESPCOP Secretary Luc De baerdemaeker President Jan P Mulier Treasurer Nick Kennedy Vice-President Yigal Leykin www.publicationslsit.org/ESPCOP www.espcop.org EMCOP airway management

EMCOP airway management Second ESPCOP Scientific meeting Multidisciplinarity Pordenone, Italy 18 sept 2010 EMCOP airway management