Airway Management & WuScope By R2 Liu Chih-Min

Difficult airway Clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both

Special Aids

Aids to ventilation The laryngeal mask airway The intubating LMA (Fastrach ) Fiberoptic intubation Lighted stylet (Lightwand) Retrograde intubation Jet ventilation GlideScope WuScope

The laryngeal mask airway Indications and advantages  independent of anatomic features  not impeded by manual inline cervical immobilization or a rigid collar  as a conduit for passing an ETT

The laryngeal mask airway Contraindications and disadvantages  incomplete protection of the airway: the risk for aspiration of gastric contents  does not physically separate the respiratory and alimentary tracts  high pulmonary inflation pressures because of increased airway resistance or very low lung compliance

The intubating LMA advantages and disadvantages  success rates for blind and fiberoptically- guided intubation through the ILMA were 96.5% and 100%  anticipated or unexpected difficult airway situations  does not reliably protect the airway from regurgitation and aspiration

Fiberoptic intubation Indications and advantages  nasotracheal approach is often simpler than the oral approach  all age groups, excellent airway visualization, ability to insufflate oxygen during the procedure, high success rate, and immediate confirmation of ETT placement

Fiberoptic intubation Contraindications and disadvantages  uncontrolled secretions, mucus, or active bleeding  Advancement of the ETT over the fiberoptic scope may be difficult, as the bevel of the tube may catch on the arytenoids, cartilages, or aryepiglottic folds

Lightwand

Lighted stylet Indications and advantages  difficult airways caused by anatomic considerations, temporomandibular immobility, large overbites, restricted mouth opening, or poor dentition  limited neck mobility or cervical spine injury

Lighted stylet Contraindications and disadvantages  no absolute contraindications  blind technique  inflammatory laryngeal disorders such as epiglottitis, retropharyngeal abscess, and tracheal stenosis  relatively contraindicated: laryngeal tumors, polyps, foreign bodies, or an unknown cause of upper airway compromise

Retrograde intubation Advantages and disadvantages  puncture through the cricothyroid membrane and passage of a guide wire “retrograde” into the oropharynx  unfavorable upper airway anatomy  Bleeding

GlideScope

Indications and advantages  difficult or impossible to intubate by conventional direct laryngoscopy  excellent laryngeal exposure  fog-resistant, high-resolution videochip  red and blue light emitting diodes providing illumination and contrast

WuScope Tubular fiberoptic laryngoscope

WuScope A tubular, curved, bi-valved, rigid blade incorporated with a flexible fiberscope Integrates the desirable features of existing rigid and flexible laryngoscopes Facilitate endotracheal intubation for the routine or difficult airway, in the awake or anesthetized patient

Structure of the Wuscope Rigid blade portion  Handle  Main-blade  Bi-valve element Flexible fiberscope portion  Body (eyepiece & insertion cord)  Battery light source  Extender

Technique for using Wuscope Patient’s head in the neutral position without necessitating tongue displacement, head extension, or neck movement 1. Introduce into the patient’s mouth at the midline, like inserting a oropharyngeal airway (may help by a tongue depressor) 2. Look through the eyepiece as the blade passes the uvula, the posterior pharyngeal wall, and the epiglottis, toward the larynx

3. With the suction catheter as a guide, align the ETT with the epiglottis by gently moving the blade sideways, or withdrawing, advancing or lifting up the device slightly 4. Advance the ETT over the suction catheter into the glottis 5. Remove the bi-valve element first, then remove the handle, main-blade, and fiberscope in one unit, leaving the ETT in place.

Indications DLT ( 35- and 37-French) placement and Tube exchange Cervical spinal injury Emergency awake intubation Supraglottic soft tissue obstruction Unfavorable anatomic features

DLT

Limitations Limited mouth opening ( minimum: mm ) Fixed upper airway deformity limitations to blood and secretions in the airway (e.g., in trauma cases) and anatomic derangements of the airway, such as abscess and tumor accidental esophageal intubation can occur

User tips Choose appropriate blade size Holding Wuscope at the handle portion Apply anti-fogging agent on fiberoptic lens Use tongue depressor for blade entry Use suction catheter as a guide Undo old intubating maneuvers Maneuver the device slowly and gently Intubate with blade in valleculla or picking up epiglottis Maintain proper orientation of airway structures

Comparison to other rigid or flexible laryngoscopes Easy maneuverability Tubular structured blade 110° embodiment of the handle and blade Separate oxygen channel and suction mechanism Fiberoptic imaging and oral airway-shape blade Tubular blade protects the fiberscope lens Built-in ETT passageway One-person operation Cost-containment feature Versatility and aesthetic appeal

Where? Can WuScope stand on the Difficult Airway Algorithm?

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