SSECOND ITERATION OF THE ASA DIFFICULT AIRWAY ALGORITHM: REVIEW AND CHANGES JONATHAN L' BENUMOF, MD

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SSECOND ITERATION OF THE ASA DIFFICULT AIRWAY
ALGORITHM REVIEW AND CHANGESJONATHAN L.
BENUMOF, MDUCSD MEDICAL CENTER
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Jonathan L. Benumof, M.D.

• UCSF graduate
• Research fellow of Eric Wahrenbrocks
• Wrote ASA difficult airway algorhithm
• Wrote (!) Anesthesia for Thoracic Surgery
• Only physician whose publication is posted
  in every VA - OR in the country

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THE ASA DIFFICULT AIRWAY ALGORITHM

• A. REVIEW THE ENTIRE ALGORITHM BRIEFLY
• B. DISCUSS THE MAJOR CHANGES IN THE SECOND
  ITERATION
• (1). PREOPERATIVE AIRWAY EVALUATION
• (2). PREOXYGENATION
• (3). USE OF LMA AS FIRST RESCUE OPTION
• (4). CONFIRMATION OF TRACHEAL
• INTUBATION OUTSIDE OF OR

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5151
ASA DIFFICULT AIRWAY ALGORITHM
RECOGNIZED
UNRECOGNIZED
(1)
(2)
(3)
GENERAL ANESTHESIA PARALYSIS
CVCI RESCUE OPTIONS
AWAKE INTUBATION
CONFIRM
(4)
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DIFFICULT AIRWAY ALGORITHM
(1)
RECOGNIZED
UNRECOGNIZED
PREOPERATIVE AIRWAY EVALUATION (11 STEPS)
GENERAL ANESTHESIA PARALYSIS
AWAKE INTUBATION
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ASA DIFFICULT AIRWAY ALGORITHM11 STEP
PREOPERATIVE AIRWAY EVALUATIONALONG THE LINE OF
SIGHT

• 1-4 FOCUS EYES ON TEETH
• 5-6 FOCUS EYES INSIDE THE MOUTH ON THE PHARYNX
• 7,8 MANDIBULAR SPACE EXAM
• 9-11 NECK EXAM

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PREOPERATIVE AIRWAY EXAMINATION
5. OROPHARYNGEAL CLASSIFICATION
6. R/O NARROW HIGH ARCHED PALATE
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7. MANDIBULAR SPACE LENGTH TMD INDEX OF A
OR P OF LARYNX
?
T
3 F B OR 6 CM
?
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• 8. MANDIBULAR SPACE
• COMPLIANCE
• LENGTH OF
• NECK
• THICKNESS OF NECK
• RANGE OF
• MOTION OF
• HEAD AND NECK

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RECOGNIZED
DIFFICULT AIRWAY
UNRECOGNIZED
UNCOOPERATIVE
PROPER PREPARATION
PATIENT
MASK VENT
NONPROBLEMATIC
GENERAL ANESTHESIA PARALYSIS
AWAKE INTUBATION CHOICES
FAIL
SURGICAL AIRWAY
REGIONAL ANESTHESIA
SUCCEED
CANCEL CASE, REGROUP
CONFIRM
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PATIENTS WHO NEED MAXIMAL PRE-02

• PATIENTS WITH O2 TRANSPORT ABNORMALITIES
  (DESATURATE
• THE FASTEST)
• 2. PATIENTS WITH DIFFICULT
• AIRWAYS (MAY NEED MORE TIME
• TO SOLVE A CVCI SITUATION)

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CAUSES OF SUBMAXIMAL PRE-O2

• INSUFFICIENT TIME OF
• BREATHING FIO2 1.0
• 2. TAKING MASK ON AND OFF
• FIO2 1.0 ROOM AIR
• 3. LEAK UNDER/AROUND MASK
• FIO2 ? ROOM AIR

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HOW DO YOU KNOW YOU ARE ACHIEVING MAXIMAL PRE-O2?

• MASK HELD CONTINUOUSLY TO FACE
• I.E., HAND OR STRAPS 3-5 MINUTES
• 2. RESERVOIR BAG MUST MOVE
• IN WITH EACH INHALATION
• OUT WITH EACH EXHALATION
• 3. GOOD EXHALATION CAPNOGRAPHY

REQUIRES A LITTLE EXPLANATION/SEDATION
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PaO2 BEFORE AND AFTER FAST TRACK AND TRADITIONAL
METHODS OF PREOYGENATION
NO SIGNIFICANT DIFFERENCE BETWEEN FAST TRACK AND
TRADITIONAL PaO2 VALUES
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TIME TO SaO2 90 FOLLOWING FAST TRACK AND
TRADITIONAL METHODS OF PREOXYGENATION
TIME TO SaO2 90, SECONDS, MEANS SD
TYPE OF PATIENT
AUTHOR
FAST TRACK
TRADITIONAL
GAMBLE
NORMAL
408 108
534 60
ELDERLY
212 92
VALENTINE
406 75
MACARTHY
ELDERLY
222 96
324 102
STATISTICALLY SIGNIFICANT GREATER TIME TO SaO2
90 BETWEEN TRADITIONAL AND FAST TRACK METHODS
OF PRE-O2
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From Campbell. Br. J Anaesth 1994 723-4
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DIFFICULT AIRWAY
RECOGNIZED
UNRECOGNIZED
PRE-O2
UNCOOP
PATIENT
GENERAL ANESTHESIA PARALYSIS
AWAKE INTUBATION
MASK VENTILATION
NO (EMERGENCY PATHWAY)
YES (NONEMER- GENCY PATHWAY)
RESCUE OPTIONS
INTUBATION CHOICES
FAIL
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DEFINITION OF OPTIMAL L-SCOPEINTUBATION ATTEMPT

• REASONABLY EXPERIENCED ENDOSCOPIST
• NO SIGNIFICANT MUSCLE TONE
• OPTIMAL SNIFF POSITION
• OPTIMAL EXTERNAL LARYNGEAL PRESSURE
• CHANGE LENGTH OF BLADE X1
• CHANGE TYPE OF BLADE X1

?
?
?
?
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DIFFICULT AIRWAY
RECOGNIZED
UNRECOGNIZED
PRE-O2
UNCOOP
GENERAL ANESTHESIA PARALYSIS
PATIENT
AWAKE INTUBATION
MASK VENTILATION
NO (EMERGENCY PATHWAY)
YES (NONEMER- GENCY PATHWAY)
RESCUE OPTIONS
INTUBATION CHOICES
FAIL
(CONTINUOUS VENTILATION FIBEROPTIC TECHNIQUES)
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CONTINUOUS VENTILATION FIBEROPTIC TECHNIQUE
ANESTHESIA MASK WITH SELF-SEALING DIAPHRAGM FOR
FOB PLUS AIRWAY INTUBATOR
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FOB
CONTINUOUS VENTILATION FIBEROPTIC TECHNIQUE
TO ANES. CIRCUIT
BRONCH ELBOW
NASEL RAE
LMA
BOWL OF LMA
LMA,
N-ETT mm ID
.
.
FOB THROUGH VOCAL CORDS
5
7.0
33, 4
6.0
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MASK VENTILATION
YES (NONEMERGENCY PATHWAY)
NO (EMERGENCY PATHWAY)
INTUBATION CHOICES
RESCUE OPTIONS
FAIL
AWAKEN
SURGICAL AIRWAY
ANESTHESIA WITH MASK VENTILATION
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DEFINITION OF OPTIMAL MASK VENTILATION

• BILATERAL JAW THRUST AND
• MASK SEAL REQUIRES 2 PERSONS
• BIG OROPHARYNGEAL AIRWAY
• CONSIDER BILATERAL BIG
• NASOPHARYNGEAL AIRWAY
• (BUT VASOCONSTRICT FIRST)

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DEFINITION OF OPTIMAL MASK VENTILATION

• BILATERAL JAW THRUST AND
• MASK SEAL REQUIRES 2 PERSONS
• BIG OROPHARYNGEAL AIRWAY
• CONSIDER BILATERAL BIG
• NASOPHARYNGEAL AIRWAY
• (BUT VASOCONSTRICT FIRST)

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MASK VENTILATION
YES (NONEMERGENCY PATHWAY)
NO (EMERGENCY PATHWAY)
INTUBATION CHOICES
RESCUE OPTIONS
FAIL
SURGICAL AIRWAY
AWAKEN
ANESTHESIA WITH MASK VENTILATION
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PAST ASA DA-A
MASK VENTILATION
YES (NONEMERGENCY PATHWAY)
NO (EMERGENCY PATHWAY)
LMA, COMBITUBE, TTJV
SURGICAL AIRWAY
AWAKEN
INTUBATION CHOICES
CONFIRM
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NO EMERGENCY PATHWAY
PRESENT ASA DA-A
MASK VENTILATION
RESCUE OPTIONS
YES NON- EMERGENCY PATHWAY
CONSIDER/ ATTEMPT LMA FIRST
YES
NO
AWAKEN
COMBITUBE TTJV
SURGICAL AIRWAY
INTUBATION CHOICES
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CVCI OPTIONS CHOOSING BETWEEN THE SUPRAGLOTTIC
MECHANISMS (LMA, CT) AND SUBGLOTTIC MECHANISMS
(TTJV, SURG AIRWAY)
CAUSE OF CVCI
VENTILATORY MECHANISM
SPECIFIC CHOICE
GIVEN ANATOMY NO PATHOLOGY
LMA, COMBITUBE
SUPRAGLOTTIC
TTJV, SURGICAL AIRWAY
PERIGLOTTIC PATHOLOGY
SUBGLOTTIC
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ASA DIFFICULT AIRWAY ALGORITHM
RECOGNIZED
(1)
UNRECOGNIZED
(2)
(3)
GENERAL ANESTHESIA PARALYSIS
CVCI RESCUE OPTIONS
AWAKE INTUBATION
CONFIRM
(4)
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IS THE TUBE IN THE TRACHEA IN A LOCATION OUTSIDE
THE OR? (PRIMARY FOCUS) IN THE OR?
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SIGNS OF TRACHEAL INTUBATION

• FAILSAFE FOB ? SEE TBT
• CARTILAGENOUS RINGS

SEE ETT BETWEEN CORDS

• ALMOST FAILSAFE PETCO2 AND EDD
• EVERYTHING ELSE NOT FAILSAFE
• AND CAN FOOL YOU

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S OF C CONFIRM TRACHEAL INTUBATION WITH USE
OF CO2 AND/OR ESOPHAGEAL DETECTION DEVICES WHERE
EVER TRACHEAL INTUBATION OCCURS

• ASA BASIC MONITORING STANDARDS
• 2. ASA DIFFICULT AIRWAY ALGORITHM
• 3. NEW AHA ACLS GUIDELINES

SAY SO
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CONFIRMATION OF TRACHEAL INTUBATION

• END-TIDAL CO2 (PETCO2) EASYCAP
• DETECTOR CARDIAC OUTPUT MUST
• BE PRESENT TO SHOW TRACHEAL
• PLACEMENT OF THE ETT
• ESOPHAGEAL DETECTOR DEVICE (EDD)
• CARDIAC OUTPUT DOES NOT NEED TO
• BE PRESENT TO SHOW TRACHEAL
• PLACEMENT OF THE ETT
• ALGORITHM FOR USING THE CO2
• DETECTOR AND EDD TOGETHER

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THE EASY CAP CO2 DETECTOR
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CONFIRMATION OF TRACHEAL INTUBATION

• END-TIDAL CO2 (PETCO2) EASYCAP
• DETECTOR CARDIAC OUTPUT MUST
• BE PRESENT TO SHOW TRACHEAL
• PLACEMENT OF THE ETT
• ESOPHAGEAL DETECTOR DEVICE (EDD)
• CARDIAC OUTPUT DOES NOT NEED TO
• BE PRESENT TO SHOW TRACHEAL
• PLACEMENT OF THE ETT
• ALGORITHM FOR USING THE CO2
• DETECTOR AND EDD TOGETHER

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THE ESOPHAGEAL DETECTOR DEVICE
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CONFIRMATION OF TRACHEAL INTUBATION

• END-TIDAL CO2 (PETCO2) EASYCAP
• DETECTOR CARDIAC OUTPUT MUST
• BE PRESENT TO SHOW TRACHEAL
• PLACEMENT OF THE ETT
• ESOPHAGEAL DETECTOR DEVICE (EDD)
• CARDIAC OUTPUT DOES NOT NEED TO
• BE PRESENT TO SHOW TRACHEAL
• PLACEMENT OF THE ETT
• ALGORITHM FOR USING THE CO2
• DETECTOR AND EDD TOGETHER

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SUMMARY

• THE EASYCAP AND EDD S OF C
• THE EASYCAP AND EDD, ARE SIMPLE, EASY,
• RELIABLE, QUICK ALMOST FAILSAFE METHODS
• IF YOU ARE CURRENTLY ? S OF C
• I.E., EASYCAP AND EDD NOT IMMEDIATELY
• AVAILABLE EVERYWHERE
• CHANGE NOW, IT WILL SAVE LIVES
• (AND YOU A LAWSUIT)

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ASA DIFFICULT AIRWAY ALGORITHM
RECOGNIZED
(1)
UNRECOGNIZED
(2)
(3)
GENERAL ANESTHESIA PARALYSIS
CVCI RESCUE OPTIONS
AWAKE INTUBATION
CONFIRM
(4)
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RESPIRATORY EVENTS Posner, APSF Newsletter 2001
16(3)37-39
of Claims in Decade
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DEATH AND BRAIN DAMAGE Posner, APSF Newsletter
2001 16(3)37-39
of Claim In Decade
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ASA DIFFICULT AIRWAY ALGORITHM ? RELATIONSHIP TO
? DAMAGE

• ANESTHESIA COMMUNITY IS MORE AIRWAY
• CONSCIOUS ? BETTER PREOP EVALUATION ?
• MORE AWAKE INTUBATIONS SOME UNNECESSARY,
• SOME ? DAMAGE
• ANESTHESIA COMMUNITY MORE WILLING TO
• AWAKEN PATIENTS IF CANNOT INTUBATE, CAN
• VENTILATE DEVELOPS
• IF CVCI ? MORE CVCI OPTIONS ? APPLIED FASTER
• PLAN ? B ? C, ETC. THINKING AHEAD