1. Airway Management of Patients with a Difficult Airway Orlando Hung Departments of Anesthesia and Surgery, Dalhousie University, Halifax, Nova Scotia Canada

3. Disclosure This presenter does not have any financial relationship with any device companies.

4. Objectives Review basic principles of airway management Context-sensitive Airway Management Device-Dependent Airway management

5. FIGURE 39–22 Difficult airway algorithm developed by ASA Task Force on Guidelines for Difficult Airway Management (Modified from American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice guidelines for the management of the difficult airway. Anesthesiology 78:597, 1993) Copyright © 2000, 1995, 1990, 1985, 1979 by Churchill Livingstone

12. 50 Ways to Intubate the Trachea

15. These algorithms will work if there is: Time Proper preparation Equipment Assistance

16. Principles of Airway Management

17. Case Presentation A 34 y.o. lady scheduled for laparotomy for a pelvic mass 80 kg, 150 cm (BMI=35.6) No major medical problems Airway examination showed that she has a small mouth opening (3.5 cm), Mallampati IV airway, receding chin with a thyromental distance <4cm, a short neck, but good neck mobility

18. What are your options to ventilate and oxygenate this patient? Awake with spontaneous ventilation (regional technique) Bag Mask Ventilation? Extraglottic device (LMA, Combitube, etc.)? Tracheal intubation? Surgical Airway?

19. What alternative intubating techniques can be considered? Direct laryngoscopy with a Macintosh laryngoscope together with a “bougie”? The use of a video-laryngoscope? Flexible bronchoscope? Lightwand intubation? Intubation through the Fastrach (Intubating LMA)? Digital intubation? Blind nasal intubation? Retrograde intubation? Cricothyrotomy or tracheotomy?

20. Plans A.General Anesthesia (GA), tracheal intubation with a video-laryngoscope B.Awake intubation using whatever technique you are most comfortable with C.Use of an extraglottic device (LMA- ProSeal, LMA-Classic, etc) if necessary D.Cricothyrotomy if needed

21. What if she is 16 weeks pregnant? Your plans are: A.Regional anesthesia B.Secure an airway by whatever means awake if at all possible

22. What if she is 16 weeks pregnant with bowel perforation, peritonitis and sepsis? A.Regional anesthesia remains controversial B.Secure the airway awake if at all possible

23. What if she is in septic shock with severe hypotension and hypoxemia? A.Secure the airway awake with a flexible bronchoscope? B.Rapid Sequence Induction and Intubation (RSI) with a video-laryngoscope? C.Awake tracheotomy?

24. What if this is not an emergency OB case, but she is mentally challenged and unco-operative? A.Secure the airway awake would be difficult even with sedation B.Secure the airway using a video-laryngoscope under GA with mask induction and spontaneous respiration C.Secure the airway using a video-laryngoscope under GA following iv induction D.The use of extraglottic device

25. What if this mentally challenged patient needs an emergency airway intervention in an MRI unit? A.Can you bring a Macintosh laryngoscope into the MRI unit? B.What about a video-laryngoscope? C.Can you use an extraglottic (iGel, LMA, etc.)? D.What about a blind nasal intubation? E.Digital intubation?

26. What if you are working in Haiti with minimal resources? RSI with a Macintosh laryngoscope + an Eschmann Tracheal Introducer (bougie) An Extraglottic device (LMA-Classic, or LMA-ProSeal)? Lightwand intubation? BMV? Surgical AW?

27. Factors that influence how we manage the airway of a patient: Can I ventilate the patient with a BMV, an extraglottic device, or through a tracheal tube? Failing that, can I get a surgical airway easily? Emergency? Cyanotic? Do I have time? Pregnant? A child? Co-operative? Aspiration risk? Any assistance? Available resources? Skills with the airway devices

28. Difficult Laryngoscopic Intubation? When we identify a potentially difficult laryngoscopic intubation, we must resist the inclination to persist with direct laryngoscopy. With the currently available resources, airway practitioners should be able to choose an appropriate device or technique to effectively manage a difficult laryngoscopy with alternative plans depending on the situation or environment as well as the skills of the practitioner.

29. Strategy to manage patients with a difficult airway: Plan A Plan B Plan C Plan D These plans should be modified or changed according to the environment or situations.

30. Principles of Airway Management

32. 50 Ways to Intubate the Trachea

33. Device Dependent Airway Management Management

35. The Bad

38. How are you going to manage this patient’s airway?

39. How can I ventilate and oxygenate this patient? Can I use the bag-mask-ventilation? Can I use an extraglottic device (LMA, Combittube, etc.)? Can I place a tube in the trachea? What about a surgical airway?

40. Summary We should focus on ventilation and oxygenation in airway management Plans to manage the airway of a patient depend on many factors and situations and all airway practitioners should modify their approaches to meet these challenges. All airway practitioners should avoid relying on a single airway device or technique.

41. Learning New Tricks?

45. Successful Airway Management Requires A Team