Difficults airway
- 1. 05/17/14 1 DIFFICULT AIRWAY MANAGEMENTDIFFICULT AIRWAY MANAGEMENT Dr . J. EDwarD Johnson. M.D., D.C.h.Dr . J. EDwarD Johnson. M.D., D.C.h. asst. ProfEssor , DEPt. ofasst. ProfEssor , DEPt. of anaEsthEsiology,anaEsthEsiology, KgMCh.KgMCh. When you can’t breath, nothing else matters
- 2. IF YOU GET A CALL TO ATTEND THIS CASE 2 CHECK YOUR PULSE RATE
- 3. DEFINITION American society of Anesthesiologist (ASA) suggested (difficult to ventilate) that when sign of inadequate ventilation could not be reversed by mask ventilation or oxygen saturation could not be maintained above 90% or (difficult to intubate) if a trained Anaesthetist using conventional laryngoscope take’s more than 3 attempts or more than 10 minute are required to complete tracheal intubation
- 4. PREVALENCE • Even with proper evaluation only 15 to 50 % of difficult airway were picked up • While difficult face mask ventilation in general is about 1:10,000 out of which again 15% proved to be the difficult intubation , • While incidence of extreme difficult or abandon intubation in general surgery patients are 1:2000 but in obstetrics is 1:300
- 5. 05/17/14 5 • Causes of difficult intubation • Basic airway evaluation (Lemon Law ) • Management plan for Anticipated difficult airway – Plan A, Plan B , Plan C • Gallery of tools • The Unexpected Difficult Airway • ASA Difficult airway algorithm DISCUSSION
- 6. CAUSES OF DIFFICULT INTUBATION Anaesthetist 1. Inadequate preoperative assessment. 2. Inadequate equipments. 3. Experience not enough. 4. Poor technique. 5. Malfunctioning of equipment. 6. Inexperience assistanance Patient 1. Congenital causes 2. Acquired causes
- 7. Anatomical factors affecting Larangoscopy 1. Short Neck. 2. Protruding incisor teeth. 3. Long high arched palate. 4. Poor mobility of neck. 5. Increase in either anterior depth or Posterior depth of the mandible decrease in Atlanto Occipital distance
- 8. Basic airway evaluation in all patients • Previous anaesthetic problems • General appearance of the neck, face, maxilla and mandibule • Jaw movements • Head extention and movements • The teeth and oro-pharyngx • The soft tissues of the neck • Recent chest and cervical spine x-rays 05/17/14 8
- 9. Dr. Binnions Lemon Law: An easy way to remember multiple tests… • Look externally. • Evaluate the 3-3-2 rule. • Mallampati. • Obstruction? • Neck mobility.
- 10. L: Look Externally • Obesity or very small. • Short Muscular neck • Large breasts • Prominent Upper Incisors (Buck Teeth) • Receding Jaw (Dentures) • Burns • Facial Trauma • Stridor • Macroglossia
- 11. E-Evaluate the 3-3-2 rule 11 3 fingers fit in mouth 3 fingers fit from mentum to hyoid cartilage 2 fingers fit from the floor of the mouth to the top of the thyroid cartilage
- 12. M- Mallampati classification Class-1 Class-11 Class-111 Class-1V soft palate, fauces; uvula, anterior and the posterior pillars. the soft palate, fauces and uvula soft palate and base of uvula Only hard palate
- 13. Cormack & Lehane Grading 05/17/14 13
- 14. Validity of the Test (II) Cormack Grade Gr. 1 Gr. 2 Gr. 3 Gr.4 Class 1 (73.8%) 59.5% 14.3% 0 0 Class 2 (19%) 5.7% 6.7% 4.7% 1.9% Class 3 (7.14%) 0 0.5% 4.3% 2.4% Mallampati class Total 210 patients
- 15. O: Obstruction? BloodBlood VomitusVomitus TeethTeeth EpiglottisEpiglottis DenturesDentures TumorsTumors Impaled ObjectsImpaled Objects
- 16. N-Neck mobility -Measurement of Atlanto-Occepital Angle
- 17. ThyroMental Distance 17 • Measure from upper edge of thyroid cartilage to chin with the head fully extended. • A short thyromental distance equates with an anterior larynx . • Greater than 7 cm is usually a sign of an easy intubation • Less than 6 cm is an indicator of a difficult airway • Relatively unreliable test unless combined with other tests.
- 19. MANAGEMENT PLAN OF ANTICEPATED DIFFICULT AIRWAY 1. Discussion with colleagues in advance. 2. Equipment tested before. 3. Senior help backup. 4. Definite initial plan (A) for ventilation and intubation. 5. Definite plan (B) than option of awake intubation. 6. Ideal situation surgery team standby.
- 20. Anesthesiology 2001, 95: 754-759 Succinylcholine itself cannot save your account. (Esp. when you did not do good pre-oxygenation.) Pre-oxygenation
- 21. Pre-oxygenation: How Much Is Enough? Two techniques common in use: 1. Tidal volume breathing (TVB) of oxygen for 3–5 min 2. Deep breaths (DB) 4 times within 0.5 min Both are equally effective in increasing arterial oxygen tension (Pao2 ). Anesth Analg 1981; 60: 313–5
- 22. Consider the merits and feasibility Awake Intubation vs Intubation after induction of GA Non-Invasive technique vs Invasive technique for initial approach for initial approach Preservation of spontaneous vs Ablation of spontaneous Ventilation ventilation 22
- 23. What are we going to do if we don’t get the Tube? • Plans “A”, “B” and “C” • Know this answer before you tube.
- 24. Plan “A”: (ALTERNATE) • Different Length of blade • Different Type of Blade • Different Position
- 25. Plan “B”: (BVM and BLIND INTUBATION Techniques ) • Can you Ventilate with a BVM? (Consider two person mask Ventilation) • Combi-Tube? • LMA an Option?
- 26. What do we do when faced with a Can’t Intubate Can’t Ventilate situation? • Plan “C”: (CRIC) Needle, Surgical,
- 27. Failure -Why does it happens? • No critical discussion with colleagues about proposed management plan • No request for experienced help • Exaggerated idea of personal ability • Ill-conceived plan A and/or plan B • Poorly executed plan A and/or plan B • Persisting with plan A too long, starting the rescue plan too late • Not involving, and preparing, surgical colleagues 27
- 29. GALLERY OF TOOLS 29 1. Rigid laryngoscope blades of alternate design and size 2. Tracheal tube guides. (stylets, ventilating tube changer, light wands & GEB) 3. Laryngeal mask airways 4. Flexible fiberoptic intubation equipment 5. Retrograde intubation equipment 6. Noninvasive airway ventilation (esophageal tracheal Combitube, transtracheal jet ventilator) 7. Emergency invasive airways (Needle & surgical cricothyrotomy) 8. An exhaled CO2 detector
- 30. Rigid laryngoscope blades of alternate design and size 30 Macintosh Magill Miller Polio Mc Coy
- 32. Stylette Devices 32 Lighted Stylette Endotracheal Tube Introducer
- 33. 33 GUM ELASTIC BOUGIE (GEB) – First used in England – Cheap – Good in patients in whom only epiglottis is visualized
- 34. Supraglottic Airways 34 1.Combitube 2. Laryngeal Mask Airway (LMA ) and Intubating LMA (ILMA)
- 35. The Esophageal- tracheal Combitube 35 •Useful as emergency airway •Two lumens allow function whether place in esophagus or trachea •Esophageal balloon minimizes aspiration
- 38. VARIANTS OF LMA • LMA – classic (standard) • LMA – flexiable (reinforced) • LMA – unique (disposable LMA) • LMA – Fastrach (intubating LMA) • LMA – Proseal (gastric LMA) 05/17/14 38
- 39. LMA – Fastrach (intubating LMA) • Rigid, anatomically curved, airway tube that is wide enough to accept an 8.0 mm cuffed ETT and is short enough to ensure passage of the ETT cuff beyond the vocal cords • Rigid handle to facilitate one- handed insertion, removal • Epiglottic elevating bar in the mask aperture which elevates the epiglottis as the ETT is passed through • Available in three sizes, one size for children, two sizes for adults 39
- 40. LMA C-Trach • Ventilation • Visualization • Intubation 40
- 41. LMA-Proseal • High seal pressure - up to 30 cm H20 - Providing a tighter seal against the glottic opening with no increase in mucosal pressure • Provides more airway security • Enables use of PPV in those cases where it may be required • A built-in drain tube designed to channel fluid away and permit gastric access for patients with GERD 41
- 42. Fiber opticFiber optic HIGH FREQUENCY VENTILATION 42
- 43. 43 DIFFICULT AIRWAY MANAGEMENT:DIFFICULT AIRWAY MANAGEMENT: Can’t IntubateCan’t Intubate Retrograde Intubation
- 46. TFE catheter: prevent the ET tube form redundancy over the guidewire decrease trauma, increase success rate
- 50. TheUnexpectedDifficultAirway • Experienced help may not be immediately available • Special equipment may not be immediately available • A general anaesthetic has usually been administered • A long acting relaxant may have been given • Backup airway management plans may be poorly thought out 50
- 51. Techniques for managing the unexpected difficult airway include Manipulation of the patients airway and position e.g. more or less pillows, laryngeal pressure, Oral airways, nasal airways in a range of size Different laryngoscopy blades e.g. •Miller •Magill •Robershaw •Mackintosh Bougies and stylettes Laryngeal mask airways Combitube 51
- 52. Difficult airway 52 Not able to ventilate Not able to intubate or Not able to ventilate and Not able to intubate
- 53. Techniques for Difficult Airway Management• . Techniques for Difficult Intubation • Optimal external laryngeal • manipulation • Alternative laryngoscope blades • Intubating stylet or tube changer • Laryngeal mask airway as an intubating conduit • Light wand (maximum of 2 attempts?) • Alternative technique of intubation -Awake intubation - Blind intubation (oral or nasal) - Fiberoptic intubation - Retrograde intubation • Invasive airway access 53 Techniques for Difficult Ventilation Two-person mask ventilation Supraglottic airways; Oral and nasopharyngeal airways •Esophageal tracheal Combitube •Laryngeal mask airway Subglottic invasive airways; •Invasive airway access •Transtracheal jet ventilation
- 54. 1 alternative 1 alternative 2 alternative 2 alternative 3 alternative 3 alternative 4 alternative 4 alternative 1 Manipulation of airway different blade, bugie 2 LMA, ILMA, Combitube 3 Trantracheal Jet Ventilation 4 Cricothireotomy, Tracheostomy
- 55. Commercial Cricothyrotomy Kit • If you are familiar with this kit, I suggest you try it first. • Use Seldinger technique or knife cutting • Direct connection to ventilator
- 56. 56 DIFFICULT AIRWAY MANAGEMENT:DIFFICULT AIRWAY MANAGEMENT: Can’t Intubate, can’t ventilateCan’t Intubate, can’t ventilate • Surgical Airway – Tracheostomy too slow – Cricothyroidotomy quick and allows placement of 6.0 OET
- 57. Emergency airway • Unorthodox method: not generally accepted, better than nothing 1. Connect the hub of the cath to the ventilator via a 3 mm ET tube adaptor. 2. Connect the hub of the cath to a 5-ml syringe then insert a 7.0 mm ET tube inside, inflate the cuff, then connect to the ventilator. 3. Connect the hub of the cath to a 3-ml syringe then insert an adaptor form a 7.5 mm ET tube inside, then connect to the ventilator
- 60. Connect to a Traditional Ventilator Higher respiratory pressure required (mimic TTJV). use O2 flush button. Self-inflated reservoir bag can be used as well.
- 61. 05/17/14 61 DIFFICULT AIRWAY GENERAL ANESTHESIA +/- PARALYSIS RECOGNIZED PROPER PREPARATION ASA DIFFICULT AIRWAY ALGORITHM UNRECOGNIZED AWAKE INTUBATION CHOICES SUCCEED FAIL SURGICAL AIRWAY MASK VENTILATION NO YES EMERGENCY PATHWAY NON -EMERGENCY PATHWAY LMA COMBITUBE TTJV INTUBATION CHOICES INTUBATION CHOICES SURGICAL AIRWAY SUCCEED FAIL CONFIRM ANESTHESIA WITHMASK VENTILATION AWAKEN SURGICAL AIRWAY EXTUBATE OVER JET STYLET REGIONAL ANESTHESIA CANCEL CASE REGROUP Intubationchoices include use of different laryngoscope blades,LMA as an intubation conduit(with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer,light wand, retrograde intubation, and blind oral or nasal intubation. * * * AWAKEN
- 62. Take home message • Be familiar with two alternative methods of intubating technique and use it regularly in your day today practice eg; LMA, GEB, FOI. • So that you won’t fumble at the time of crisis 05/17/14 62
- 63. Difficult Airway Maxims “It is preferable to use superior judgement – to avoid having to use superior skill”. ?’s 05/17/14 63
- 64. GOOD LUCK 05/17/14 64 Challenges mayChallenges may bebe Waiting for youWaiting for you