iairwayassessment.ppt
- 1. RSI Airway Assessment New Hampshire Division of Fire Standards & Training and Emergency Medical Services 2011
- 2. Purpose of this Module Review Airway Anatomy Learn Advanced Airway Assessment Techniques 3-3-2 Laryngoscope View Grading Mallampati Classifications BURP
- 3. IF Endotracheal Intubation fails, you must have a back-up plan...
- 4. Upper Airway
- 5. Upper Airway
- 7. Thyroid versus Cricothyroid Cartilage Thyroid cartilage used in “BURP” maneuver. Does not form a complete ring around the trachea. Cricothyroid Cartilage used in CricoidPressure, does form a full ring around the trachea allowing for the compression of the esophagus.
- 10. Lower Airway
- 11. 1. Preparation A two-part process: Assess the risks Prepare the equipment
- 12. Assess the Risks
- 13. Difficult Airways - Assess the Risks “The difficult airway is something one anticipates; the failed airway is something one experiences.” -Walls 2002
- 14. How do you know if your patient is going to be difficult to intubate… …and does it really matter?
- 15. Some Predictors of a Difficult Airway C-spine immobilized trauma patient Protruding tongue Short, thick neck Prominent upper incisors (“buckteeth”) Receding mandible High, arched palate Beard or facial hair Dentures Limited jaw opening Limited cervical mobility Upper airway conditions Face, neck, or oral trauma Laryngeal trauma Airway edema or obstruction Morbidly obese
- 16. Additional Predictors: Medical History Joint disease Acromegaly Thyroid or major neck surgeries Tumors, known abnormal structures Genetic anomalies Epiglottitis Previous problems in surgery Diabetes Pregnancy Obesity Pain issues
- 17. Assess the Risk Identifying a potentially difficult airway is essential to preparing and developing a strategy for successful ETI and also preparing an alternate plan in the event of a failed ETI.
- 18. Objectives Identify 4 areas of airway difficulty Predict a difficult airway using the following mnemonics: MOANS LEMONS DOA
- 19. Airway Difficulties Difficult to ventilate with a BVM Difficult laryngoscopy Difficult to intubate
- 20. Difficult to Bag (MOANS) Mask Seal Obesity or Obstruction Age > 55 No Teeth Stiff
- 21. Mask Seal Small Hands Wrong Mask Size Oddly Shaped Face Bushy Beard Blood/Vomit Facial Trauma MOA NS
- 22. Obesity or Obstruction Obesity Heavy chest Abdominal contents inhibit movement of the diaphragm Increased supraglottic airway resistance Billowing cheeks Difficult mask seal Quicker desaturation MOA NS
- 23. Obesity or Obstruction 3rd Trimester Pregnancy Increased body mass Quick desaturation Increased Mallampati Score Gravid uterus inhibits movement of the diaphragm MOA NS
- 24. Obesity or Obstruction Obstructions Foreign Body Angioedema Abscesses Epiglottitis Cancer Traumatic Disruption/Hematoma/Burns MOA NS
- 25. Age > 55 Associated with BVM difficulty, possibly due to loss of tone in the upper airway MOA NS
- 26. No Teeth Face tends to “cave in” Consider leaving dentures in for BVM and remove for intubation MOA NS
- 27. Stiff Refers to Poor Compliance Reactive Airway Disease COPD Pulmonary Edema/Advance Pneumonia History of Snoring/Sleep Apnea Also predicts a higher Mallampati score MOA NS
- 28. Difficult Laryngoscopy & Intubation LEMONS Look Externally Evaluate 3-3-2 Mallampati Score Obstruction Neck Mobility Scene and Situation
- 29. LOOK Externally Beards or facial hair Short, fat neck Morbidly obese patients Facial or neck trauma Broken teeth (can lacerate balloons) Dentures (should be removed) Large teeth Protruding tongue A narrow or abnormally shaped face LEM ONS
- 30. EVALUATE 3-3-2 Bottom of Jaw/Chin to Neck > 3 fingers Jaw/Palate > 3 fingers wide Mouth opens > 2 fingers wide Any single indicator has poor specificity LEM ONS
- 31. EVALUATE 3-3-2 Mouth Opens at least 3 finger widths. Three finger widths thyromental distance. Two finger widths mandibulohyoid distance. LEM ONS
- 32. EVALUATE 3-3-2 Will patients mouth open wide enough to accommodate 3 fingers? Will 3 fingers fit between the mentum and hyoid bone? Will 2 fingers fit between the hyoid and thyroid notch? If not, expect a difficult intubation LEM ONS
- 33. Mouth opens at least 3 fingers width? LEM ONS
- 34. Thyromental Distance Distance from the mentum to the thyroid notch. Ideally done with the neck fully extended. Can be done in-line Helps determine how readily the laryngeal axis will fall in line with the pharyngeal axis. LEM ONS
- 35. Thyromental Distance If the thyromental distance is short, <3 finger widths, the laryngeal axis makes a more acute angle with the pharyngeal axis and it will be difficult to achieve alignment. Less space to displace the tongue. LEM ONS
- 37. Mandibulohyoid Distance- 2 fingers? Measured from the mentum to the top of the hyoid bone. The epiglottis arises from the thyroid and remains dorsal to the hyoid bone. Therefore, the position of the hyoid bone marks the entrance to the larynx. LEM ONS
- 39. Mandibulohyoid Distance When the position of the hyoid bone is caudal or relatively caudal, a large portion of the tongue is situated in the hypopharynx instead of the mouth. During laryngoscopy, this large hypopharyngeal tongue mass further compromises the compliance needed for its displacement LEM ONS
- 40. Mandibulohyoid Distance Patients who have a longer mandibulohyoid distance, greater then 2 finger widths, tend to be more difficult to intubate. A more caudal hyoid bone thus indicates a relatively caudal larynx. LEM ONS
- 41. Upper & Lower Face Measure the size of the upper face as compared to the lower face. Should be roughly the same. If the lower face is longer than the upper face then you should anticipate some degree of difficulty lining up the structures. LEM ONS
- 42. Upper and lower face equal? LEM ONS
- 43. Upper and lower face equal? LEM ONS
- 45. Mallampati Score Have patient sit up, and stick out tongue without phonating May be unable to properly assess this in an emergent field situation Modified version is to use a laryngoscope blade like a tongue blade to visualize the oropharynx – (not as sensitive or specific) LEM ONS
- 46. Mallampati Classification Relates to tongue size to pharyngeal size. Performed with patient in a sitting position, head neutral, mouth open wide and tongue protruding to the maximum. The Subsequent Classification is assigned based upon the pharyngeal structures visible. LEM ONS
- 47. Mallampati Classification Class I: Visualization of the soft palate, fauces, uvula, and anterior & posterior pillars LEM ONS
- 48. Mallampati Classification Class II: Visualization of the Soft palate, fauces and uvula. LEM ONS
- 49. Mallampati Classification Grade III: Visualization of the soft palate and the base of the uvula. LEM ONS
- 50. Mallampati Classification Grade IV: The soft palate is not visible at all. LEM ONS
- 51. LEM ONS
- 53. Laryngoscopy or intubation may be more difficult in the presence of an obstruction Anatomy Trauma Foreign body obstruction Edema (burns) LEM ONS Obstruction
- 54. Obstructions Laryngoscopic View Grades Grade 1: Full aperture visible Grade 2: Lower part of cords visible Grade 3: Only epiglottis visible Grade 4: Epiglottis not visible LEM ONS
- 55. Obstructions Laryngoscopic View Grades Graded in order from the best view to worst. Grade 1: Visualization of the entire laryngeal apeture LEM ONS
- 56. Obstructions Laryngoscopic View Grades Grade 2: Visualization of just the posterior portion of the laryngeal aperture. Grade 3: Visualization of only the epiglottis Grade 4: Visualization of the soft palate only. LEM ONS
- 57. Obstructions Laryngoscopic View Grades A severe grade III or IV view with failed endotracheal intubation occurs in 0.05- 0.35% of patients LEM ONS
- 59. Cormack & Lehane Grading Grade I = success & ease of intubation <1% <5% 10-30% % listed = incidence LEM ONS
- 60. Neck Mobility Ideally the neck should be able to extend back approximately 35° Problems: Cervical Spine Immobilization Ankylosing Spondylitis Rheumatoid Arthritis Halo fixation LEM ONS
- 61. Scene and Situation (SEE) Scene safety Environment Do you have a reasonable chance to get the tube? Space, positioning, access Egress Will you be able to ventilate during egress? A respiratory rate of 4 is better than a rate of 0! Enough meds for a long extrication? LEM ONS
- 62. “BURP” – a.k.a. “External Laryngeal Manipulation” Backward, Upward, Rightward Pressure: manipulation of the trachea 90% of the time the best view will be obtained by pressing over the thyroid cartilage Differs from the Sellick Maneuver
- 63. To Summarize Airway assessment is a critical part of the RSI process The difficult airway assessment must be performed prior to ALL RSI attempts. While this criteria helps identify difficult airways, it does not guarantee an easy intubation—Be Prepared!