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Case discussion A case of difficult intubation

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Title: Case discussion A case of difficult intubation


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Case discussionA case of difficult intubation
  • Intern ???
  • Department of anesthesiology
  • NTUH
    2001/12/25

3
Brief history (1)
  • Name?X? Chart No4099581
  • Sex/Agemale , 59 y/o Bed No9D-13-1
  • Admission date2001/12/4
  • Past History 1.DM , fresh case
  • 2.denied other systemic
    disease
  • 3.smoking and drinking when
    young
  • 4.denied any food and drug
    allergy
  • 5.no recent travel and
    trauma history

4
Brief history (2)
  • Posterior neck swelling without discharge
    initially since 11/19.
  • He visited our ER for discharge and tenderness of
    the wound on 11/29.
  • Low grade fever,leukocytosis and high CRP value
    were noted.
  • Unasyn,Metronidazole and Gentamicin were given
    with only minor improvement of lab data and
    clinical condition.
  • He was discharge under cellulitis and suggested
    OPD F/U.
  • Because of purulent discharge persisted,the
    patient visited our ER again on 12/4.
  • Deep neck infection was suspected ,he was
    admitted for further care and op evaluation.

5
Brief history (3)
  • PE erythematous induration all over the
    posterior neck region mild tenderness.
  • CXR shows normal heart size with slightly
    increased lung markings. Tortuous aorta is noted.
  • SPINE CERVICAL AP. LAT showed marked
    degenerative change of C-spine with calcification
    of post. nuchal ligament. post. spur are noted at
    C5 6 7.

6
Brief history (4)
  • Neck CT without/with contrast enhancement shows
  • 1. soft tissue swelling with low density change
    at dorsal aspect of neck and occpital region
    symmetrically, the fat planes are blurred. there
    is indistinct interface of the swollen soft
    tissue with the posterior neck muscles (splenius
    capitus and probably semispinalis). infectious
    process is considered, probably cellulitis and
    myositis.
  • 2. the spine is intact
  • 3. no abnormal enlarged LAPs

7
Brief history (5)
  • Pre op 59 y/o male with DM was diagnosed neck
    abscess s/p ID.
  • Op methodDebridement on 12/7
  • ASA class III
  • Neck movement decrease,extension(-)
  • short neck , small mandible
  • Risk of difficult intubation was explained to
    family.

8
Anesthesia course (see record)
  • Induction of general anesthesia followed by
    direct laryngoscopy and oral intubation.
  • -gt difficult intubation
  • -gt Flexible fiberoptic intubation
  • --gt IVG propofol infusion

9
Prediction and Management of Difficult Tracheal
Intubation
  • Introduction
  • Predicting Difficult Intubation
  • Preparation for Intubation
  • Planning Anaesthesia

10
Introduction
  • During routine anaesthesia the incidence of
    difficult tracheal intubation has been estimated
    at 3-18.
  • Class I the vocal cords are visible
  • Class II the vocals cords are only partly
    visible
  • Class III only the epiglottis is seen
  • Class IV the epiglottis cannot be seen.
  • Cormack RS, Lehane J. "Difficult intubation
  • in obstetrics." Anaesthesia 1984391105-11

11
Predicting Difficult Intubation (1)
  • "sniffing the morning air" position
  • History and examination
  • Specific Screening Tests to Predict Difficult
    Intubation.
  • View obtained during Mallampati test
  • 1. Faucial pillars, soft palate and uvula
    visualised
  • 2. Faucial pillars and soft palate visualised,
    but uvula
  • masked by the base of the tongue
  • 3. Only soft palate visualised
  • 4. Soft palate not seen.
  • Samsoon GLT, Young JRB. "Difficult tracheal
  • intubation a retrospective study."
  • Anaesthesia 198742487-90

12
Predicting Difficult Intubation (2)
  • Thyromental distance
  • Grade 3 or 4 Mallampati who also had a
    thyromental distance of less than 7cm were likely
    to present difficulty with intubation
  • Frerk CM. "Predicting difficult intubation."
    Anaesthesia 1991461005-8
  • Sternomental distance
  • A sternomental distance of 12.5cm or less
    predicted difficult intubation
  • Savva D. "Prediction of difficult tracheal
    intubation." British Journal of Anaesthesia
    199473149-53

13
Predicting Difficult Intubation (3)
  • Protrusion of the mandible
  • If the patient cannot get the upper and lower
    incisors into alignment intubation is likely to
    be difficult.
  • Calder I, Calder J, Crockard HA. "Difficult
    direct laryngoscopy in patients witH cervical
    spine disease." Anaesthesia 199550756-63
  • X-ray studies
  • Various studies have been used to try to predict
    difficult intubation by assessing the anatomy of
    the mandible on X-ray. These have shown that the
    depth of the mandible may be important, but they
    are not commonly used as a screening test.

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Preoperative assessment
  • A combination of the above tests is better than
    using only one. The modified Mallampati,
    thyromental distance, ability to protrude the
    mandible and craniocervical movement are probably
    the most reliable.

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Preparation for Intubation (1)
  • Anaesthetists should be ready to deal with
    difficulties in intubation at any time. The
    correct equipment must be immediately available.
    This will include
  • laryngoscopes with a selection of blades
  • a variety of endotracheal tubes
  • introducers for endotracheal tubes (stylets or
    better, flexible bougies)
  • oral and nasal airways

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Preparation for Intubation (2)
  • a cricothyroid puncture kit (a 14 gauge cannula
    and jet insufflation with high pressure oxygen is
    the simplest and cheapest kit
  • reliable suction equipment
  • a trained assistant
  • laryngeal mask airways, sizes 3 4

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After intubation
  • The anaesthetist should ensure that the patient
    is in the optimal position for intubation and
    must be able to oxygenate the patient at all
    times.
  • After intubation correct placement of the tube
    should be confirmed by
  • a stethoscope listening over both lung fields in
    the axillae
  • observing the tube pass through the cords
  • successful inflation of the chest on manual
    ventilation

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Special techniques for intubation
  • Awake intubation under local anaesthesia
  • Oral intubation
  • Nasal intubation is the best method of awake
    intubation using a fibreoptic bronchoscope or
    other intubating fibrescope via the nose.

19
Retrograde intubation (1)
  • is a technique first described in Nigeria
  • Waters DJ "Guided blind endotracheal intubation
    for patients with deformities of the upper
    airway." Anaesthesia 196318158-62
  • Retrograde intubation has recently been used
    successfully for traumatised airways when
    conventional techniques had failed
  • Barriot P, Riou B. "Retrograde technique for
    tracheal intubation in trauma patients."Critical
    Care Medicine. 198816712-3
  • the membrane between the cricoid and first
    tracheal ring can also been used.
  • Shanther TR. "Retrograde intubation using the
    subcricoid region." British Journal of
  • Anaesthesia. 199268109-12

20
Retrograde intubation (2)
21
The Laryngeal Mask Airway
  • is a common device in anaesthesia and can often
    provide a good airway in patients in whom
    intubation is difficult. Following insertion the
    anaesthetist may use it to maintain the airway
    during anaesthesia, or may use it as a route to
    allow tracheal intubation.

22
The McCoy laryngoscope
  • is designed with a movable tip which allows the
    epiglottis to be lifted and intubation often made
    easier
  • McCoy EP, Mirakhur RK. "The levering
    laryngoscope." Anaesthesia 199348516-9

23
  • A light wand is a long flexible device which has
    a bright light at the end and can be directed
    into the trachea with an endotracheal tube
    mounted over it
  • Robelen GT, Shulman MS. "Use of the lighted
    stylet for difficult intubations in adult
    patients (abstract)." Anesthesiology 198971A439
  • The Combi-tube is a tube which may be inserted
    blindly and used to ventilate the patient in an
    emergency
  • Frass M, Frenzer R. Zahler J, Lilas W, Leithner
    C. "Ventilation via the esophageal tracheal
    combitube in a case of difficult intubation."
    Journal of Cardiothoracic Anaesthesia
    19871565-8

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Planning Anaesthesia
  • During general anaesthesia patients must never be
    given muscle relaxants unless the anaesthetist
    can be certain of being able to ventilate them.
  • When the anaesthetist faces unexpected difficulty
    in intubation the priority is to ensure adequate
    mask ventilation and oxygenation of the patient.
  • Multiple attempts at endotracheal intubation may
    result in bleeding and oedema of the upper airway
    making the task even more difficult. Often it is
    better to accept failure after a few attempts and
    move on to a pre-planned failed intubation
    sequence
  • King TA, Adams AP. "Failed tracheal intubation."
    British Journal of Anaesthesia199065400-414

25
Failed intubation
  • If intubation proves impossible the anaesthetist
    should consider whether to allow the patient to
    wake up and carry on surgery with regional
    anaesthesia, or whether to abandon the surgery
    altogether. In situations where surgery is of an
    urgent nature it may be prudent to carry on the
    general anaesthetic under face mask anaesthesia
    if the airway is easy to maintain.
  • If the airway is impossible to maintain and the
    patient is becoming hypoxic, an emergency
    cricothyroidotomy is required. If time allows an
    emergency tracheostomy can be considered.

26
Difficult airway algorithm (ASA)
  • Practice guidelines for management of the
    difficult airway. A report by the American
    Society of Anesthesiologists Task Force on
    Management of the Difficult Airway.
    Anesthesiology. 1993 Mar78(3)597-602.

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ASA Algorithm Part 1
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ASA Algorithm Part 2
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Awake Intubation Pathway
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  • Non-surgical techniques for awake intubation
    include laryngoscopy, fiberoptic bronchoscopy and
    retrograde intubation. Surgical access may be
    secured by awake tracheostomy.
  • Awake intubation requires patient cooperation and
    should be performed with local anesthesia. See
    Local Anesthesia for more information.
  • If awake intubation efforts fail, the patient is
    unlikely to have compromised ventilation.
    Consider canceling the case, other intubation
    options or surgical access to the airway.

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Intubation After Induction Pathway
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  • After induction of anesthesia, if the initial
    intubation attempts are unsuccessful, consider
    returning to spontaneous ventilation, awakening
    the patient and calling for help.
  • If mask ventilation is adequate, go to the
    Non-Emergency Pathway. If mask ventilation is
    inadequate go to the Emergency Pathway.
  • If mask ventilation becomes inadequate at any
    time while following the Non-Emergency Pathway,
    go to the Emergency Pathway

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Non-Emergency Pathway
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  • Follow the Non-Emergency Pathway when the patient
    is anesthetized, intubation is unsuccessful and
    mask ventilation is adequate. If mask ventilation
    becomes inadequate go directly to the Emergency
    Pathway.
  • Consider alternative approaches including
    fiberoptic intubation, intubation stylet, blind
    intubation, light wand and retrograde intubation.
  • If failure after multiple attempts, consider
    awakening the patient, surgical airway or surgery
    under mask anesthesia.

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Emergency Pathway
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  • Follow the Emergency Pathway when the patient is
    anesthetized, intubation is unsuccessful and mask
    ventilation is inadequate.
  • Time is critical. Call for help. Do one more
    intubation attempt or emergency non-surgical
    airway ventilation or emergency surgical airway.
  • Do not continue to attempt a previous
    unsuccessful technique.
  • Emergency non-surgical airway ventilation
    techniques include transtracheal jet
    ventilation, intratracheal jet stylet, laryngeal
    mask, oral and nasopharyngeal airways, two person
    mask ventilation, and rigid ventilating
    bronchoscope.
  • Emergency non-surgical airway ventilation
    techniques are temporizing measures. Establish a
    definitive airway as soon as possible.

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