Airway management for patients with cervical spine disorders Presented by R3 吳佳展

Case presentation 30 year-old man 30 year-old man Hyperextension injury Hyperextension injury C4-5 HIVD C4-5 HIVD Muscle power: lower extremities 1, upper 3 Muscle power: lower extremities 1, upper 3 HR, BP, vital capacity within normal range HR, BP, vital capacity within normal range Intubated with light wand under general anesthesia Intubated with light wand under general anesthesia No neurological deterioration after surgery No neurological deterioration after surgery

Trauma patients Pathology of cervical spine Pathology of cervical spine Stability Stability Preoperative neurological deficits Preoperative neurological deficits Airway patency Airway patency Respiratory function Respiratory function Cardiovascular compromise Cardiovascular compromise Full stomach Full stomach

Trauma patients Other associated injuries Other associated injuries Facial injury: interfere with mask ventilation Facial injury: interfere with mask ventilation 1~2% of trauma patients have cervical spine injury 1~2% of trauma patients have cervical spine injury 10% of high-risk patients (head-first fall, high speed motor vehicle accidents) 10% of high-risk patients (head-first fall, high speed motor vehicle accidents) Stabilization makes intubation more difficult Stabilization makes intubation more difficult

evaluation Neck pain or tenderness: only valid in alert patients without other painful lesions Neck pain or tenderness: only valid in alert patients without other painful lesions Neurological examination Neurological examination Plain films: lateral, AP, open mouth. Sensitivity~90% Plain films: lateral, AP, open mouth. Sensitivity~90% CT scan CT scan MRI MRI

Airway management No guidelines in this area No guidelines in this area Awake or under general anesthesia Awake or under general anesthesia Nasal or oral Nasal or oral Blind, larygoscope, fiberoptic bronchoscope, Bullard scope, Combitube, light wand, LMA, Fastrach, gum elastic bougie, Wu ’ s scope Blind, larygoscope, fiberoptic bronchoscope, Bullard scope, Combitube, light wand, LMA, Fastrach, gum elastic bougie, Wu ’ s scope Surgical airway: tracheostomy, cricothyroitomy Surgical airway: tracheostomy, cricothyroitomy

Factors determining methods used Urgency: most rapid and secure method is preferred Urgency: most rapid and secure method is preferred Experience of anesthesiologist Experience of anesthesiologist Patients ’ cooperation Patients ’ cooperation Airway anatomy Airway anatomy Mechanism of injury: flexion, extension Mechanism of injury: flexion, extension

“ standard ” Oral laryngoscope with manual in-line stablization Oral laryngoscope with manual in-line stablization Blind nasal intubation in awake patients Blind nasal intubation in awake patients Nasal fiberoptic intubation Nasal fiberoptic intubation

Comparison between methods Outcome Outcome Radiological study: normal patients, with cervical spine pathology but without instability, cadaver Radiological study: normal patients, with cervical spine pathology but without instability, cadaver Upper or lower cervical spine injury Upper or lower cervical spine injury

Outcome study No difference between awake or GA, nasal or oral intubation (retrospective) No difference between awake or GA, nasal or oral intubation (retrospective) few studies comparing other airway management methods based on outcome, possibly because they are not widely used few studies comparing other airway management methods based on outcome, possibly because they are not widely used

Effect of airway maneuver Cadaver study Cadaver study Unstable C5-C6: chin lift=jaw thrust=oral intubation>nasal intubation in spine movement Unstable C5-C6: chin lift=jaw thrust=oral intubation>nasal intubation in spine movement Unstable C1-C2: space available for spinal cord oral=nasal>chin lift and jaw thrust Unstable C1-C2: space available for spinal cord oral=nasal>chin lift and jaw thrust

Bullard vs. Macintosh Patients requiring GA with normal cervical spine Patients requiring GA with normal cervical spine Measured with c-arm Measured with c-arm Extension: BUL with ILS (in-line stabilization)< BUL=MAC with ILS<MAC Extension: BUL with ILS (in-line stabilization)< BUL=MAC with ILS<MAC Intubation time: in reversed order Intubation time: in reversed order

No neck motion? Blind nasal Blind nasal Nasal fiberoptic intubation: may cause the least movement compared other conventional methods Nasal fiberoptic intubation: may cause the least movement compared other conventional methods Trachlight Trachlight Fastrach Fastrach Combitube Combitube

Fastrach Patients with cervical pathology (metastasis, disc prolapse, OPLL) Patients with cervical pathology (metastasis, disc prolapse, OPLL) With light wand guide With light wand guide Flexion and posterior displacement C0~C5 Flexion and posterior displacement C0~C5

Fastrach Cadaver Cadaver Pressure sensor placed at C2-3 Pressure sensor placed at C2-3 Control: nasal/oral, laryngoscope/ fiberscope Control: nasal/oral, laryngoscope/ fiberscope Fastrach produces greater pressure against cervical spine and greater posterior displacement Fastrach produces greater pressure against cervical spine and greater posterior displacement

Fastrach vs. laryngoscope Flexion vs. extension Flexion vs. extension Fastrach used in extension injury? Fastrach used in extension injury? Laryngoscope used in flexion injury? Laryngoscope used in flexion injury?

Trachlight vs. Fastrach Patients with cervical spine pathology Higher success rate at first attempt Less time required No data about cervical spine movement was provided

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