1. Difficult Airway

2. Definition The clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both. represents a complex interaction between patient factors, the clinical setting, and the skills of the practitioner American Society of Anesthesiologists Task Force on Management of the Difficult Airway, 2013

3. Cause serious soft tissue damage Hypoxaemic anaesthetic death and brain damage

4. Airway assessment Aim is to anticipate –Difficult ventilation –Difficult intubation –Difficulty with patient cooperation or consent –Difficult tracheostomy

5. History Previous history of difficult airway Airway-related symptoms/disease Difficult airway bracelet/card Previous surgery/radiotherapy to head & neck Trauma to head & neck Head & neck infection Obstructive lesions/foreign body in airway

6. Systemic conditions Connective tissue diseases –RA –Scleroderma Endocrine –Acromegaly OSA Pregnancy Congenital syndromes

7. Physical Examination L – Look externallyLook externally E – Evaluate 3-3-2 rulesEvaluate 3-3-2 rules M – Mallampati scoreMallampati score O – Obstruction N – Neck mobility

8. Special Investigation Chest X-ray CT, MRI (neck, chest)

9. Physical Examination Atypical facial features or shape Edentulous mouth Morbid obesity Facial hair Protruding or “buck” teeth Protruding tongue Facial or neck trauma

11. Physical Examination Three finger mouth opening Three finger mentum to hyoid Two finger floor of mouth to thyroid cartilage

13. Difficult Airway Society guidelines Plan A: Initial tracheal intubation plan. Plan B: Secondary tracheal intubation plan, when Plan A has failed. Plan C: Maintenance of oxygenation and ventilation, postponement of surgery, and awakening the patient, when earlier plans fail. Plan D: Rescue techniques for ‘can’t intubate, can’t ventilate’ (CICV) situation

14. Clinical scenario of difficult intubation in an adult patient after induction of general anaesthesia and muscle paralysis, usually with a non-depolarising neuromuscular blocking drug

15. Performed in optimal conditions after ensuring adequate muscle relaxation and appropriate position of the head and neck Use of optimum external laryngeal manipulation or Sellick maneuver If, despite these measures, there is still a grade 3 or 4 view, then alternative techniques will be needed. –introducer (‘gum elastic bougie’) and ⁄ or –different laryngoscope i.e McCoy and straight laryngoscope Oxygenation is maintained with mask ventilation between intubation attempts.

16. Basic preparation for difficult airway Inform patient Skilled assistance Suction Preplanned strategy/algorithm

17. Basic preparation for difficult airway Pre O 2 Supplemental O 2 during the difficult airway management

18. Case scenario Mr M, 41, comorbid HPT not on follow up. Alleged MVA at 6 am. Sustained severe crush injury of right lower limb. No other external/internal injury. On cervical collar. Planned for AKA under GA Last meal at 5 am BP: 132/86 HR: 116 Hb: 10.6 K:3.2

19. Case scenario Preoxygenation with 100% O2 Cricoid pressure Induction –IV Fentanyl 100 mcg –IV Propofol 120 mg –IV Rocuronium 50 mg Manual in-line stabilization 1 st laryngoscopy  CLIII with cricoid pressure  esophageal intubation Mask ventilation 2 nd laryngoscopy  doubtful ETT placement 3 rd laryngoscopy  tracheal intubation

23. Greater risk of regurgitation or vomiting Short duration of succinylcholine increases the risk of laryngospasm and difficulty with laryngoscopy during recovery of neuromuscular function

26. Difficult intubation cart