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Title: Difficult%20Airway%20Management%20in%20Anesthesia%20%20Part%20II


1
Difficult Airway Management in Anesthesia Part
II
  • Chan Wei-Hung MD
  • Department of Anesthesiology
  • National Taiwan University Hospital

2
Awake Intubation Topicalization of Airway
  • This should be done in such an order
  • Nasopharynx
  • Oropharynx
  • Vocal cord and trachea

Generally speaking, vocal cord and its vincity is
the most sensitive site and the most common
barrier to successful awake fiberoptic
intubation others are usually tolerable under
the spray of local anesthetics.
3
Sensory Innervations of Airway
  • Nasal mucosa sphenopalatine ganglion (V2)
    anterior ethmoidal nerve (ciliary ganglion)
  • Oropharynx and supraglottic region
    glossopharyngeal nerve
  • Larynx superior laryngeal nerve (internal
    branch)
  • Trachea recurrent laryngeal nerve

4
Innervation of Nasopharynx
5
Anesthesia of Nasopharynx
6
Anesthesia of Nasopharynx
7
Drugs to Use
  • 4 lidocaine with 1200,000 epinephrine
  • 4 lidocaine with 0.250.5 phenylephrine
  • Lower concentration of lidocaine makes a slower
    onset.
  • Apply bilaterally wait 23 min to take effect.

8
A Case Report
  • Intraoperative death of a 21-kg, 4-yr-old boy
    during bilateral myringotomies and adenoidectomy
  • Unmeasured amount of 0.5 phenylephrine on the
    surgical site to control bleeding
  • BP was 180/110 mmHg and heart rate was 160
    beats/min
  • 2.5 mg labetalol was given
  • Bradycardia developed, and copious amounts of
    pink, frothy fluid were found from ET tube.
  • He died 16 h later in ICU.

. Anesthesiology 92(3)859-64, 2000
9
Guidelines for Usage
  1. Phenylephrine for adults should not exceed 0.5 mg
    or 20 µg/kg in children.
  2. Mild-to-moderate hypertension resulting from
    phenylephrine use, in a healthy individual,
    should be closely monitored for 1015 min before
    antihypertensive medications
  3. Direct vasodilators or a antagonists are
    appropriate treatments.
  4. The use of ß blockers and calcium-channel
    blockers should be avoided.
  5. Glucagon may be used to treat ß blocker-induced
    heart failure / pulmonary edema.

. Anesthesiology 92(3)859-64, 2000
10
Lubrication of the Nasal Passage
  • 7.5 / 7.0 mm nasopharyngeal airway soaked in
    viscous lidocaine
  • Determination of the nostril
  • Determination of the tube size (the bigger the
    better ?)

11
Glossopharyngeal Nerve Block
2ml of 12 lidocaine each side Aspiration before
injection May have the patient in sitting or
back-up position
26 spinal needle Advance 0.5 cm into mucosa
12
Superior Laryngeal Nerve Block
  • The patients neck is slightly hyperextended.
  • Superior border of lateral wing of thyroid
    cartilage and greater cornu of hyoid bone are
    palpated.
  • Advance the needle just under the greater cornu
    of hyoid bone until walk-off through the firm
    thyrohyoid membrane, aspirate then inject 12
    xylocaine 23 cc each side.

13
Superior Laryngeal Nerve Block
14
Superior Laryngeal Nerve Block
15
Transtracheal Injection
  • The patients neck is slightly hyperextended.
  • Drug 4 Lidocaine 2 ml or 2 4 ml (2 needs
    longer onset time, maybe 10 min)
  • 22 IV cath, through cricothyroid membrane, ????,
    ???air bubbles, ??????cough
  • NPO?????

16
Spray As You Go
  • Inject 0.2-1.0 ml 24 lidocaine via suction
    channel of fiberoscope (esp. near the vocal
    cord).
  • Remember to hold the suction tubing when inject.
  • Wait 30 to 60 sec. Then advance again.
  • Not as effective as nerve block.

17
The Importance of Being Anesthetized
18
Awake Intubation
  • Planned or after failed intubation
  • Fiberoptic intubation
  • Retrograde intubation
  • Blind nasal intubation

These techniques are essentially not for true
emergency situations (time-consuming).
19
Awake Fiberoptic Intubation Nasal Approach
20
Tube First or Scope First?
  • ET tube first
  • Higher possibility to cause bleeding
  • Patients feel uneasy with tube in the nasal
    passage.
  • Scope first
  • Fiberoscope has the chance to divert from
    midline.
  • Passage of ET tube through nasopharynx is not
    assured.

21
Tube First Technique
  • Choice of tube size the size does not matter!
  • Put the tube in warm water for 5 min
  • Choice of nostril left side is preferable
  • Do not do it forcefully!! (To shift to a smaller
    ET tube is a virtue.)
  • Two points of high resistance will be met.
  • After the second high resistance is passed,
    advance the tube a little more then hold on. (at
    about 15 cm)
  • Turn the tube gently while have the patient
    breathe deeply, stop at the point of the largest
    air passage.

22
Two points of high resistance
1st
2nd
1 st between turbinate and nasal septum. 2 nd
turning into oropharynx
23
Advancing the Scope
  • Always keep the black in the center of the field.
    (Esp. in distorted anatomy)
  • Identify the epiglottis.
  • Pass beneath the epiglottis then bend the scope
    upwards a little to make the opening of glottis
    in the center of the field.
  • Bingo!

24
Blood the Most Unwanted
  • Be gentle in passing the tube through the
    nasopharynx !
  • Suction not always works well, usually quite
    unsatisfactory.
  • Slightly back-up position, have the patient
    swallowing the blood.
  • Advance the scope blindly esophagus is often
    entered (which means the midline position of the
    scope is secured), then withdraw slowly. Once the
    scope slips out of esophagus, glottic opening is
    hopefully in view.

25
The Oral Approach
  • A more curved pathway compared with nasal passage
  • Less convenient in distorted anatomy
  • Prone to deviate from midline position (an
    intubating airway is helpful.)
  • Easy to cause fiberoscope damage
  • Can be done at sitting position

26
The Oral Approach
  • An oral bite is a must unless very good topical
    anesthesia (which is a rarity.)
  • Advance the tip of the scope till the posterior
    part of the tongue base then bend downwards
    nearly 90 epiglottis will appear in view.
  • Advance between epiglottis and posterior wall of
    larynx. Glottic opening would be found.

27
Causes of Failed Fiberoptic Intubation
  • Lack of expertise (most common)
  • Secretion and blood
  • Fogging of lenses
  • Poor topical anesthesia
  • Distorted anatomy
  • Fiberoscope malfunction
  • Inadvertent passage of fiberoscope through
    Murphys eye

28
Practice of Fiberoptic Intubation on Healthy
Patients More Often !
29
Retrograde Intubation
30
The Three Tenors good for the concert, disaster
for the OR.
31
Laryngeal Mask Airway (LMA)
  • Sizes
  • 1 lt6.5 kg 2-5 ml 3.5
  • 2 6.5-20 kg 10 ml 4.5
  • 2 1/2 20-30 kg 14 ml 5.0
  • 3 30-60 kg 20 ml 6.0
    (cuffed)
  • 4 60 kg 30 ml 6.5
    (cuffed)
  • 5 gt70 kg

32
Does the Size Matter?
  • It does in routine use.
  • It dose not in difficult airway management.
  • In patients with macroglossia, limited mouth
    opening, poor dentition, enlarged adenoid tissue,
    insertion of LMA is perceivably difficult the
    use of LMA in these cases should be reconsidered.
  • A smaller size than recommended may help.

33
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34
The Technique of Insertion (I)
  • Deflate the mask while pressing the bowl of the
    LMA against a flat surface.
  • Lubricate the posterior surface of the LMA.
  • After induction, patients head is slightly
    extended.
  • Insert the LMA into patients mouth, pressing the
    back firmly against the hard palate.

35
The Technique of Insertion (II)
  • LMA should be seen to flatten against the palate.
  • Push the LMA further while firmly pressing
    against the palate.
  • Once pass the tongue, the LMA can be advanced
    without resistance.
  • Inflate the cuff, then check the ETCO2 after
    several manual ventilation.
  • Secure LMA with tape, with the black line facing
    the nose.

36
Keypoints for Successful LMA Insertion
  • Practice and expertise
  • Choice of correct size
  • Proper patient positioning
  • Adherence to correct technique
  • Adequate depth of anesthesia

37
Removal of LMA
  • At deep or light level of anesthesia.
  • Do not suction inside the LMA!

38
Dont treat LMA like an ET tube!
  • Dont push over the posterior pharyngeal wall!
  • Dont suction inside the LMA!

39
After LMA Insertion
  1. Awake the patient and cancel operation.
  2. Continue the operation with LMA.
  3. Fiberoscope intubation with LMA (then change to a
    bigger ET tube).

40
Contraindications of LMA
  • Patients at the risk of aspiration
  • Patients with poor pulmonary compliance
  • Pharyngeal pathology

41
Light Wand
  • Et tube is attached to the light wand after
    lubrication both inside and outside the tube.
  • A 90-degree bend is made at the distal end of the
    tube.
  • After induction and mask ventilation is assured,
    put the patient in neutral position with the neck
    slightly extended.
  • Open the mouth and apply light wand until light
    is seen in thyroid cartilage advance the tube.

42
Problem Shooting in Light Wand
  • No light is seen in the neck
  • Light malfunction
  • Increase the length of the bent end
  • Light is seen in pyriform sinus
  • Withdraw-reapply policy

43
Admonition
  • LMA and lightwand are basically used for
    difficult intubation after induction and mask
    ventilation is assured.
  • In case of difficult mask ventilation, LMA can be
    tried in a very short time shift to cricothyroid
    membrane puncture ASAP if LMA fails after
    several attempts. Lightwand is generally not
    desirable in difficult mask ventilation.
  • Rethink and take great care when use LMA and
    lightwand in limited mouth opening!

44
Tube Exchanger
45
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46
Have an Algorithm of Yourself!
47
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48
How to Recognize Esophageal Intubation?
49
CO2 waveform in a 10 y/o boy after intubation.
Breathing sound clear bilaterally
Anesthesia Analgesia 66481, 1987
50
CO2 waveform during tracheal and esophageal
intubation.
Anesthesia Analgesia 73333, 1991
51
CO2 waveform during tracheal and esophageal
intubation afte addition of a carbonated beverage
into stomach.
Anesthesia Analgesia 73333, 1991
52
Recognition of Tracheal Intubation
  • Gold standard ETCO2
  • Normal capnography indicating tracheal
    intubation
  • CO2 may appear after several manual ventilations.
    (From alveoli to the machine)
  • CO2 level increases to normal range and persists
    after at least 5 manual ventilations.

53
Pitfalls of Auscultation
  • In the absence of ETCO2, stomach should be
    checked first!
  • In case of esophageal intubation, chest
    auscultation may reveal no obvious breathing
    sound (mimicking bronchospasm) or a false typical
    bilateral symmetrical breathing sound transuded
    from stomach.

54
How long does it take for a patient with an
unnoticed esophageal intubation to become
cyanotic / low SpO2?
55
Case Presentation
  • 42 y/o male, 87kg, severe burn over neck and
    facial area with inhalation injury. Mechanical
    ventilation is expected. You are the
    anesthesiologist who is consulted to the burn ICU
    for tracheal re-intubation because a suspected
    cuff rupture. At arrival in ICU, only an intern
    and a nurse is on the site.
  • What equipment will you take with you?
  • What do you ask them to prepare for you?
  • How to differentiate between esophageal/ tracheal
    intubation on the site?

56
Preparation for Intubation outside OR
  • MA SALT
  • Mask
  • Ambu bag
  • Suction
  • Airway
  • Laryngoscope
  • Tube

57
How to Differentiate Esophageal Intubation
outside the OR?
  • Make good use of the tube exchanger!

58
GOOD LUCK!
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