AIRWAY MANAGEMENT IN PATIENTS WITH UNSTABLE CERVICAL SPINES STRATEGIES AND TECHNIQUES - PowerPoint PPT Presentation

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AIRWAY MANAGEMENT IN PATIENTS WITH UNSTABLE CERVICAL SPINES STRATEGIES AND TECHNIQUES

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Secure airway without causing/worsening neurologic injury ... Blockade: Thyrohyoid membrane or pyriform fossa. Subglottic (Recurrent Laryngeal Nerve) ... – PowerPoint PPT presentation

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Title: AIRWAY MANAGEMENT IN PATIENTS WITH UNSTABLE CERVICAL SPINES STRATEGIES AND TECHNIQUES


1
AIRWAY MANAGEMENT IN PATIENTS WITH UNSTABLE
CERVICAL SPINESSTRATEGIES AND TECHNIQUES
  • Brad Hindman, M.D.
  • Department of Anesthesia
  • University of Iowa, College of Medicine

2
Endotracheal Intubation in Patients With Cervical
Spine Instability
  • Secure airway without causing/worsening
    neurologic injury
  • These patients are often a difficult intubation
  • Disease process
  • Methods to stabilize cervical spine

3
Motion Force During Conventional Direct
Laryngoscopy IntubationNormal Spine
4
Normal SpineCervical Spine Motion during Direct
Laryngoscopy/Intubation
5
Normal SpineLifting Force during Direct
Laryngoscopy/Intubation a,b
6
SummaryNormal Cervical Spines
  • Cervical motion may be reduced by limiting
    glottic exposure
  • Poor glottic view could pose risk with unstable
    cervical spines
  • Too much force across unstable segments

7
Motion ForceConventional Direct Laryngoscopy
IntubationUnstable Spine
8
Unstable Cervical Spine
  • Moves abnormally with motion/force of
    laryngoscopy
  • Where pathologic motion occurs depends on
  • Specific location nature of instability
  • Force applied across unstable segment

9
Unstable SpineO-C1-C2 Complex
  • Laxity of Transverse Ligament (Rheumatoid
    Arthritis, Down Syndrome)
  • Flexion Odontoid moves posteriorly towards cord
  • Intubation (extension) Theoretically, not at
    risk
  • Abnormal odontoid and/or O-C1-C2 articulations
  • Flexion/Extension C1 subluxes on C2, compressing
    cord
  • Intubation (extension) AT RISK
  • Combined bony ligamentous abnormalities - ?

10
Unstable SpineSub-axial Segments (C3-C7)Spine
Movement during Laryngoscopy/Intubation
11
SummaryUnstable Cervical Spine
  • Difficult to predict net spine motion during
    laryngoscopy
  • When cervical spine instability present
  • Minimize force applied across unstable segments
  • Minimize cervical spine motion
  • Maintain neck in neutral position

12
Effects of External Cervical SpineStabilization
MethodsNormal Spine
13
Normal SpineCollars and Manual In-Line
Stabilization (MILS)
  • Concept Prevent spine movement during intubation
  • Majernick TG Ann Emerg Med 1986 15417
  • 16 normal subjects
  • Collars did not reduce spine motion
  • MILS did appear to reduce spine motion

14
Normal SpineEffect of MILS during Direct
Laryngoscopy Intubation
15
Effects of External Cervical SpineStabilization
MethodsUnstable Spine
16
Unstable SpineEffect of Stabilization
  • Aprahamian C Ann Emerg Med 1984 13584
  • 1 cadaver complete C5-C6 ligamentous instability
  • Rigid Collar did not appear to affect spine
    movement
  • Donaldson WF Spine 1993 182020
  • 5 cadavers incomplete C5-C6 ligamentous
    instability
  • Head stabilization may have ? subluxation
    angulation
  • Lennarson PJ J Neurosurg (Spine 2) 2000 92201
  • 16 cadavers incomplete C4-C5 ligamentous
    instability
  • MILS did not prevent abnormal flexion

17
Unstable SpineComplete ligamentous laxity at
C4-C5a
18
Unstable SpineAxial Traction
  • Can result in severe distraction
  • Bivins HG Ann Emerg Med 1988 1725
  • Donaldson WF 3rd Spine 1993 182020
  • Axial traction is to be avoided during
    intubation, unless...

19
Unstable SpineEffect of MILS with O-C1-C2
Instability
20
SummaryExternal Stabilization Maneuvers Spine
MovementDuring Laryngoscopy and Intubation
  • Axial Traction
  • O-C2 Probably dangerous
  • C3-C7 Probably dangerous
  • Cervical Collars
  • O-C2 ?
  • C3-C7 No indication of benefit
  • MILS
  • O-C2 May be of benefit, maybe not
  • C3-C7 May be of benefit, maybe not
  • Nevertheless, it is the standard of care

21
Method of Manual In-Line Stabilization
(MILS)During Conventional Direct Laryngoscopy
  • Patient supine, head flat on table in neutral
    position
  • Assistant
  • Grasps both mastoid processes with fingertips
  • Cup occiput in hands without applying axial
    traction
  • Anterior portion of cervical spine collar removed
  • Allows maximal mouth opening
  • Expose anterior neck (cricoid pressure,
    retrograde wire, or surgical airway)

22
Method of MILS, continued
  • Preoxygenation ( cricoid pressure if full
    stomach)
  • Sedatives/anesthetics paralytics as indicated
  • Assistant applies force(s) equal opposite to
    those of DL to keep the head/neck in neutral
    position

23
By limiting extension at O-C2MILS often worsens
glottic view with conventional DLGlottic View
with Standard Head Neck Position vs. MILSa
24
MILS Conventional Direct Laryngoscopy
  • 10 risk of not seeing glottis
  • Lifting harder may not be advisable
  • Airway aids (bougie, light wand, fiberoscope)
  • Alternatives to Conventional Direct Laryngoscopy
  • Bullard, WuScope, Intubating LMA

25
Clinical Scenarios General Approachesto
Endotracheal IntubationEmergent Intubation with
Traumatic Cervical Spine Injury
26
Emergent Intubation and C-Spine
Trauma/InstabilityThe Cervical Spine in the
Setting of Trauma
  • 2-4 of blunt trauma patients have C-spine
    fx/dislocations
  • Cluster around C1-C2 C5-C6
  • 70 have major associated injuries
  • 50 have neurologic signs/symptoms
  • 25-50 require intubation within 24 h
  • Before complete/definitive C-spine evaluation
  • In presence of known instability
  • Effect of DL/intubation difficult to predict

27
Emergent Intubation and C-Spine
Trauma/InstabilityNeurologic Injury from
Conventional DL IntubationLow but Real
  • Hastings RH Anesthesiology 1993 78580
  • Unrecognized fx at C6-C7
  • Muckart DJJ Anesthesiology 1997 87418
  • 2 patients Unrecognized fxs at C2 C6
  • Redl G Anesthesiology 1998 891262
  • Unrecognized C2 instability

28
Emergent Intubation and C-Spine
Trauma/InstabilityAdvanced Trauma Life Support
(ATLS) Guidelines-1980s
  • Blind nasotracheal intubation for emergent
    intubation
  • (n1) Aprahamian C Ann Emerg Med 1984 13584
  • (n7) Bivins HG Ann Emerg Med 1988 1725
  • Problems
  • Often not easy
  • Often not fast
  • Often not successful
  • Sometimes contraindicated (basilar- mid-face fx)

29
Emergent Intubation and C-Spine
Trauma/InstabilityIntubation Methods In Patients
with Acute Cervical Spine Injury
30
Emergent Intubation and C-Spine
Trauma/InstabilityRisk of Neurologic Injury
  • Conventional Direct Laryngoscopy MILS
    (anesthesia, paralysis)
  • 0/374 95 confidence 0-1
  • Awake Nasotracheal Intubation
  • 0/240 95 confidence 0-2

31
Emergent Intubation and C-Spine
Trauma/InstabilityAdvanced Trauma Life Support
(ATLS) Guidelines-NOW
The most important determinant of whether to
proceed with orotracheal or nasotracheal
intubation is the experience of the doctor. Both
techniques are safe and effective when performed
properly. If orotracheal intubation is
chosen the two-person technique with in-line
immobilization should be used. - ATLS Student
Course Manual, 6th Edition, 1997
32
Emergent Intubation and C-Spine
Trauma-InstabilityConventional DL Intubation
with MILS/Trauma
  • Failed intubation reported 2-10
  • MILS can limit glottic visualization
  • Blood secretions
  • Altered anatomy (prevertebral swelling)
  • Difficult Airway algorithm (Caplan RA
    Anesthesiology 1993 78597)

33
Clinical Scenarios General Approachesto
Endotracheal IntubationNON-Emergent Intubation
with Cervical Spine Instability
34
NON-Emergent Intubation with Cervical Spine
InstabilityRosenblatt WH Anesth Analg 1998
87153
35
NON-Emergent Intubation with Cervical Spine
InstabilityAirway Anesthesia
  • Supraglottic (Superior Laryngeal Nerve)
  • Internal br. Sensory Pharynx to false cords
  • External br. Motor to cricothyroid muscle
  • Blockade Thyrohyoid membrane or pyriform fossa
  • Subglottic (Recurrent Laryngeal Nerve)
  • Sensory True vocal cords to trachea
  • Motor Intrinsic muscles of larynx
  • Blockade Transcricoid injection of local
    anesthetic
  • Combined (Topical)
  • Inhalation f nebulized local anesthetic

36
NON-Emergent Intubation with Cervical Spine
InstabilityAirway Anesthesia
  • Nasal Mucosae (Trigeminal)
  • Anesthesia and vasoconstriction
  • 4 cocaine or 3-4 lidocaine/0.25-1.00
    phenylephrine
  • Oral/Gag (Glossopharyngeal)
  • Lingual br. Posterior 1/3rd of tongue
  • Blockade Palatoglossal arch (injection or
    topical)

37
Airway Anesthesia Topical vs. BlocksReasoner
DK J Neurosurg Anesth 1995 794
38
NON-Emergent Intubation, FiberopticsDifficulties
Encountered during Elective Fiberoptic
Intubation in Patients with Cervical Spine
Diseasea,b,c,d
39
NON-Emergent Intubation, FiberopticsEndotracheal
tube catching on Glottic Structuresa
a. Katsnelson T Anesthesiology 1992 76151
40
NON-Emergent Intubation, FiberopticsEndotracheal
tube catching on Glottic Structures
41
NON-Emergent Intubation, FiberopticEndotracheal
tube catching on Glottic Structures
  • Rotate tube counterclockwise during advancement
  • Pull tongue forward during advancement
  • Patient persistence

42
NON-Emergent Intubation with Cervical Spine
InstabilityThe Bullard Laryngoscope
43
NON-Emergent Intubation with Cervical
InstabilityThe Bullard Laryngoscope
  • Potential Advantages
  • Can be faster than fiberoptics
  • Neck can be maintained in neutral position
  • Better glottic visualization with MILS

44
NON-Emergent Intubation with Cervical Spine
InstabilityConventional Laryngoscopy vs. Bullarda
45
NON-Emergent Intubation with Cervical Spine
InstabilityThe Bullard Laryngoscope
  • Notes of Caution
  • Significant learning curve
  • Not evaluated in patients with unstable spines
  • Successful intubation not a sure thing
  • 15 failure (MacQuarrie K Can J Anesth 1999
    46760)

46
NON-Emergent Intubation with Cervical Spine
InstabilityThe WuScope
47
NON-Emergent Intubation with Cervical Spine
Instability WuScope MILS vs. Conventional DL
MILSa
48
NON-Emergent Intubation with Cervical Spine
InstabilityThe WuScope
  • Potential Advantages
  • Neck can be maintained in neutral position
  • Better glottic visualization with MILS
  • Notes of Caution
  • Learning Curve
  • Not evaluated in patients with unstable spines
  • Not a sure thing

49
NON-Emergent Intubation with Cervical Spine
InstabilityThe Intubating LMA (ILMA)
50
NON-Emergent Intubation with Cervical Spine
InstabilityThe ILMA
  • Can be inserted with head neck neutral
  • Designed to allow rapid blind orotracheal
    intubation
  • Fiberoptic guided intubation also possible
  • Case reports of use in patients with unstable
    spinesa,b
  • a. Schuschnig C Anaesthesia 1999 54793
  • b. Wong JK J Clin Anesth 1999 11346

51
NON-Emergent Intubation with Cervical Spine
InstabilityThe ILMA
  • Patients in Cervical Collarsa
  • Placement generally difficult
  • Ventilation poor 40 blind intubation success
    20
  • Patients with Cervical Spine Disease (25
    unstable)b
  • ?2 attempts to place 25
  • Blind intubation success 63 esophageal
    intubation 8
  • Patients with Cervical Spine Disease (15
    unstable)c
  • ?2 attempts to place 45
  • C2-C5 displaced posteriorly 1.5-3.0 of flexion
  • a. Wakeling HG Br J Anaesth 2000 84254
  • b. Nakazawa K Anesth Analg 1999 891319
  • c. Kihara S Anesth Analg 2000 91195

52
NON-Emergent Intubation with Cervical Spine
InstabilityThe ILMA
  • Cadavers with Stable Necksa
  • ILMA Insertion/adjustment 200-400 cm H2O
    pressure on C2-C3
  • C3 displaced 1-3 mm
  • Cadavers with Unstable Necks (posterior C3)b
  • ILMA 1.71.3 mm post. displacement
  • Conventional DL 2.61.6 mm post. displacement
  • Combitube placement 3.21.6 mm post.
    displacement
  • Nasal Fiberoptic 0.10.7 mm post. displacement
  • a. Keller C Anesth Analg 1999891296
  • b. Brimacombe J Anesth Analg 2000 911274

53
NON-Emergent Intubation with Cervical Spine
InstabilityThe ILMA
  • Notes of Caution
  • Multiple attempts to correctly place often
    necessary
  • Relatively low success rate with blind intubation
  • High pressure on C2-C3, risk of spine displacement
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