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Difficult Airway Management

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Difficult Airway Management Robert J. Sharpe BSc. M.D., FRCPC Department of Anaesthesia & Perioperative Medicine ... The Artificial Airway: ... – PowerPoint PPT presentation

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Title: Difficult Airway Management


1
Difficult Airway Management
  • Robert J. Sharpe BSc. M.D., FRCPC
  • Department of Anaesthesia Perioperative
    Medicine
  • Department of Critical Care Medicine
  • Royal Columbian Hospital, New Westminster, B.C.
  • University of British Columbia

2
Airway Management
  • First
  • a few words of wisdom.

3
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4
  • Airway Management
  • DOES
  • NOT
  • (NECESSARILY)
  • MEAN
  • INTUBATION

5
And as well see latertheres even an algorithm!
6
Catch all that???
  • Excellent! Talk complete!
  • Oh well maybe not so fast.

7
Airway ManagementQuestions to Ask Yourself
(while NOT PANICKING!)
  • 1. WHY do we need to manipulate this patients
    airway?
  • - indications

8
Airway ManagementQuestions to Ask Yourself
(while NOT PANICKING!)
  • 2. WHEN do we need to do this?
  • - how urgent are the above indications

9
Airway ManagementQuestions to Ask Yourself
(while NOT PANICKING!)
  • 3. WHAT are the risks and benefits of
    manipulating this patients airway?
  • - trauma? C-spine?

10
Airway ManagementQuestions to Ask Yourself
(while NOT PANICKING!)
  • 4. WHERE do we want to do this?
  • - not USUALLY a key issue in the PACU itself,
    however
  • - unless EMERGENT, avoid manipulating the
    questionable airway in a remote location (e.g. CT
    scanner, MRI, wards, angio) - inadequate
    equipment, inadequate backup personnel. IN OTHER
    WORDS

11
  • THANK GOODNESS FOR THE
  • PACU

12
Airway ManagementQuestions to ask yourself
while NOT PANICKING!
  • HOW do I manipulate this patients airway?
  • - methods/means of mechanical ventilation
  • - medications
  • - what TOOLS do I need?
  • - bag/mask, oral airway, nasal trumpet, LMA,
    ETT etc
  • - what MEDS do I need?
  • - sedation/topicalization, inotropes, pressors
    (anticipate
  • hemodynamic changes POST-intubation)
  • - have a plan. Then have a BACKUP plan!
  • WHO do I need to assist me?
  • -RT, nursing staff, anaesthesia?, ENT?
  • - sleeping ICU fellow?

13
Airway ManagementWHY? Indications
  • Clinical
  • upper airway obstruction
  • respiratory distress (with hemodynamic
    instability or impending respiratory collapse) /
    increased work of breathing
  • impaired airway protection (altered mentation
    GCS less than 8? Go ahead and intubate.)
  • impaired ability to clear or high volume of
    secretions/need for pulmonary toilet/lavage

14
Airway ManagementWHY? Indications
  • Physiologic
  • Hypoxemia
  • persistent after O2 administration
  • Hypercapnia
  • PCO2 gt 55 with pH lt7.25
  • vital capacity lt15ml/kg with neuromuscular disease

15
The Artificial Airway WHAT are the Risks and
Benefits?
  • Benefits
  • bypasses upper airway obstruction
  • route for O2 and med. Administration
  • NAVEL (naloxone, atropine, ventolin/versed,
    epinephrine, lidocaine)
  • allows mechanical/positive-pressure ventilation
    and PEEP
  • allows suctioning of secretions/pulmonary toilet
  • allows fiberoptic bronchoscopy/lavage/biopsy

16
The Artificial Airway WHAT are the Risks and
Benefits?
  • Risks
  • trauma on insertion
  • oropharyngeal/nasopharyngeal/tracheal
    ulceration/trauma/perforation with chronic use
  • tracheomalacia
  • impaired cough
  • increased aspiration risk
  • resistance/work of breathing

17
The Artificial Airway WHAT are the Risks
(contd)?
  • impaired mucociliary function
  • increased infection risk (VAP)
  • increased resistance/work of breathing
  • Risks of mechanical ventilation in general

18
Dont Panic, but...
  • Airway management
  • single largest source for unfavourable outcomes
    in ASA closed-claims study (34 of 1541 liability
    claims)
  • 3 mechanisms of injury account for 75 of
    undesireable events
  • inadequate ventilation
  • esophageal intubation
  • difficult tracheal intubation
  • recurrent patterns of management error or injury
  • airway trauma
  • pneumothorax
  • airway obstruction
  • aspiration
  • bronchospasm

19
HOW do I minimize the Risk?
  • thorough airway history and physical examination
  • management plan for supraglottic means of
    ventilation
  • management plan for subglottic means of
    ventilation
  • alternate plan an alternate to your alternate
    plan!

20
Basic Airway Anatomy
  • airway refers to the upper airway
  • nasal and oral cavities
  • pharynx
  • larynx
  • trachea
  • principal bronchi

21
Basic Airway Anatomy
base of tongue
epiglottis
vocal cords
trachea
glottis
Insert tube here!
NOT here
22
Basic Airway Anatomy
  • trachea suspended from cricoid cartilage by
    cricotracheal ligament
  • trachea roughly 15cm lenth in adults supported
    by 17-18 C-shaped cartilages (open posteriorly
    membranous aspect overlies esophagus)
  • 1st tracheal ring anterior to C6
  • trachea ends at level of carina at T5
  • right mainstem bronchus larger in diameter and
    deviates at less acute angle than left (therefore
    aspiration or endobronchial intubation usu. to
    right side)

23
The Airway Evaluation
  • Easy (though not necessarily reliable) in the
    awake, cooperative, cognitively intact patient
  • (How often do you see awake, cooperative,
    cognitively intact patients if respirator
    distress sets in, in the PACU???)
  • quickly evaluate the urgency of the situation
  • Vital signs SpO2, HR, BP
  • is the patient protecting his/her airway?
  • Is the patient fatigued/showing signs of
    respiratory distress?
  • Proceed to history, physical, labs as
    appropriate.. And

24
  • CALL for HELP!

25
Airway ManagementEvaluation of the Airway -
History
  • Full history that one considers if time
    permitting
  • key points
  • previous intubations and ease thereof?/tracheostom
    ies?
  • known difficult airway?
  • full stomach?
  • chipped teeth, loose teeth, caps, crowns,
    bridges, dentures?
  • stridor, dysphagia, change in phonation, c-spine
    pain/instability, upper extremity neuropathies?
  • AMPLE

26
Airway Management - History
  • In the PACU the nature of the surgery may be one
    of the most important factors, e.g.
  • Carotid Endarterectomy
  • C-spine fusion
  • Microlaryngectomy
  • basically any surgical manipulation of the head
    and neck is a red flag for potentially difficult
    airway management

27
Airway ManagementEvaluation of the Airway -
Physical
  • Basic areas of evaluation
  • TMJ
  • TMD and submandibular soft-tissue compliance
  • NROM - atlanto-occipital extension
  • Mallampati/Samsoon Young Classification

28
  • dentition
  • beard
  • identification of cricothiroid membrane
  • identification of (obvious) pharyngeal pathology
  • intraoperative Cormack Lehane class (if
    available)

29
What we like to see
30
Sometimes the difficult airway is obvious...
31
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33
Sometimes its not quite so obviousat least
until direct laryngoscopy
34
Complete obstruction
Normal
35
Attempting to differentiate the difficult from
the not-so-difficult
36
Mallampati Classification
37
Airway Evaluation
  • Mallampati/Samsoon Young classification
  • unfortunately neither significantly sensitive nor
    specific
  • in a trial of 675 patients, the index detected
    only 5 of 12 difficult airways and gave 139 false
    positives

38
So weve determined this patient needs airway
interventionweve evaluated this patients
airway...now were going to manage their airway
for them...
39
Airway ManagementHOW do I manage this patients
airway?
  • Preoxygenation
  • aka denitrogenation
  • replacement of N2 volume (gt69 of FRC) with O2
  • provides reservoir of O2 for diffusion into
    alveolar capillaries after onset of apnea
  • 100 O2 x 5 min yields 10 min. O2 reserve
    following apnea (w/o cardiopulmonary disease and
    with normal VO2)

40
Airway ManagementHow do we free this airway?
  • First, recall
  • any condition which increases O2 consumption
    (VO2) or decreases O2 supply/diffusion will
    dramatically decrease this reserve
  • e.g. obesity, sepsis, pregnancy, pulmonary
    parenchymal disease, intrapulmonary/intracardiac
    shunt, thryotoxicosis etc etc etc...

41
Airway ManagementThe HOW PreOxygenate
  • Faster alternative to 100 O2 x 5 minutes
  • 4 vital capacity breaths at 100 O2 over 30
    seconds
  • still, shorter time to desaturation that with
    100 x 5 minutes, but more effective than room
    air (FiO2 21) alone
  • 8 deep breaths of FiO2 1.0 over 60 seconds

42
Preoxygenation contd
  • pre-oxygenation implies ultimately, more
    definitive securing of the airway
  • pre-oxygenation may be active or passive
    depending on patient status
  • if patient awake and cooperative, attempt the
    above deep breathing or vital capacity techniques
  • if patient already apneic or once rendered apneic
    with medications, bag/mask ventilate the patient
    yourself

43
Face Mask Ventilation
  • Positioning
  • sniffing position
  • renders base of the tongue and the epiglottis
    more anterior
  • aligns axes of oral cavity, pharynx, and trachea
    (in preparation for laryngoscopy)

44
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45
The sniffing position aligns
  • the pharyngeal axis
  • the laryngeal axis
  • the oral axis

46
Laryngoscope technique
  • Grasp with the left hand
  • Insert into right CORNER of patients mouth
  • You want to SWEEP the tongue out of the way
  • Follow the curve of the tongue with the tip of
    the laryngoscope
  • You do not want to push the tongue inward
  • Lodge the tip of the laryngoscope at the base of
    the epiglottis
  • You do NOT want to trap the epiglottis under the
    blade, you want it to move up as you compress its
    base
  • PUSH

47
Laryngoscopy
  • Thats right PUSH
  • Push the tongue, mandible and epiglottis up
    toward the far corner (wall to ceiling) of the
    room
  • You should (regardless of size, age or medical
    speciality) be able to lift the patients head
    off the bed by simply pushing

48
Laryngoscopy
  • We TRY not to flex at the WRIST
  • The push is from the arm, NOT FROM THE WRIST
  • Remember
  • Teeth are breakable!
  • Teeth can be aspirated!
  • Teeth are embarrassing on CXR and on rounds!

49
What youll see
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51
How we interpret what we see with experience, in
time
52
Laryngeal Grade
Class I the vocal cords are visibleClass II the
vocals cords are only partly visibleClass III
only the epiglottis is seenClass IV the
epiglottis cannot be seen
53
So, now what???
  • Plan A
  • Insert ETT
  • Size 7.0 8.0 female
  • Size 7.5 8.5 male
  • (Age/4) 4 for children
  • /- stylet
  • But never forget the previously manipulated
    airway (as frequently the case in PACU) is
    ANGRY!!!
  • While the virgin airway may tolerate a 7.5 just
    fine the inflamed, angry, post-op airway may
    need a 7.0, a 6.0 or worse

54
Plan B
  • What if the tube wont pass or you can only see a
    Grade III tiny little opening?
  • Regroup
  • Try again
  • TRY SOMETHING DIFFERENT each time you try again
    theres no point in repeating your initial
    mistake
  • Theres LOTS available

55
Plan B (and Plan C and Plan D and. Plans E
through Z!)
  • Repositioning the head
  • Cricoid pressure/BURP
  • Stylet
  • Bougie
  • (lighted stylet, fiberoptic bronchoscope, LMA,
    combitube, retrograde intubation,
    cricothyroidotomy, etc etc etc)
  • REMEMBER if you can just BAG and MASK ventilate
    a patient, you may save their life with that
    alone

56
Theres even an algorithm or a few of
them. (dont worry about it)
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59
and remember what we said to begin with
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