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THE DIFFICULT AIRWAY

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DIFFICULT VENTILATION Combitube LMA Oral and nasopharyngeal airways Rigid ventilating bronchoscope Invasive access Transtracheal jet ventilation Two-person mask ... – PowerPoint PPT presentation

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Title: THE DIFFICULT AIRWAY


1
THE DIFFICULT AIRWAY
  • Martha Richter, MSN, CRNA

2
THE DIFFICULT AIRWAY PRACTICE GUIDELINES
  • Designed by ASA last updated 2003
  • the clinical situation in which a clinically
    trained anesthesiologist experiences difficulty
    with face mask ventilation, difficulty with
    tracheal intubation, or both.
  • 30 deaths from anesthesia b/o inability to
    manage difficult airways

3
DIFFICULT AIRWAY GUIDELINES REVIEW
  • Difficult face mask ventilation
  • Not possible because of inadequate mask seal,
    excessive gas leak, excessive resistant to gas
    movement (in out).
  • Signs may include absent/inadequate chest
    movement, absent/inadequate BS, auscultation
    sounds of severe obstruction, cyanosis, SpO2
    decreasing/inadequate, absent/inadequate
    spirometric measures of exhaled gas flow,
    hemodynamic changes as with hypoxia/hypercarbia

4
DIFFICULT AIRWAY GUIDELINES REVIEW
  • Difficult laryngoscopy
  • No view after many attempts with conventional
    laryngoscopy
  • Difficult intubation
  • Requires multiple attempts in the absence of
    tracheal pathology
  • Failed intubation

5
DIFFICULT AIRWAY GUIDELINES REVIEW
  • PRINCIPLE ADVERSE OUTCOMES
  • DEATH
  • Brain injury
  • Cardiopulmonary arrest
  • Unnecessary trach
  • Airway trauma
  • Dental damage

6
DIFFICULT AIRWAY GUIDELINES REVIEW
  • The guidelines were developed by a task force and
    advisory group formed by anesthesiologists from
    private and academic practice

7
DIFFICULT AIRWAY GUIDELINES REVIEW
  • AIRWAY Evaluation
  • The airway history should be conducted to
    determine factors that may indicate the
    presence of a difficult airway. Review of old
    records may be helpful

8
DIFFICULT AIRWAY GUIDELINES REVIEW
  • Physical exam of the airway should not be based
    on only one parameter.
  • Additional information should be gathered based
    on the airway evaluation and the physical
    evaluation of the airway

9
DIFFICULT AIRWAY ALGORITHM REVIEW
  • Along with the Mallampati score, consider
  • Cervical extension
  • Size compliance of mandibular space
  • Interincisor distance
  • Lengththickness of neck
  • Presence of overriding maxillary teeth
  • Ability to voluntarily prognoth
  • Configuration of palate
  • Presence of beard, large breasts, relevent
    cancers, abscesses, hemorrhage, tracheal
    disruption

10
DIFFICULT AIRWAY ALGORITHM REVIEW
  • PREPARING
  • Availability of difficult airway cart
  • Inform the pt/respons person of risks
    procedures needed for management
  • Have a 2nd trained person available
  • Good pre-O2
  • Continue to deliver O2 during procedureby NC,
    facemask, LMA, insufflation, jet vent during
    attempts facemask, blow-by, NC after extubation

11
DIFFICULT AIRWAY GUIDELINE REVIEW
  • Develop a strategy
  • Depends on practitioner skills, anticipated
    surgery, and the condition of the patient
  • 4 basic possibilities
  • Difficult ventilation
  • Difficult intubation
  • Difficult/uncooperative pt (may not consent)
  • Difficult trach

12
DIFFICULT AIRWAY ALGORITHM REVIEW
  • CONSIDERATIONS
  • Awake vs asleep
  • Noninvasive vs invasive
  • Preservation spontaneous vent vs ablation of
    spontaneous vent during attempts

13
DIFFICULT AIRWAY ALGORITHM REVIEW
  • Identify alternative approaches (whats your
    backup?)
  • DIFFICULT INTUB
  • Alt blades, awake intub, blind intub
  • FOB, intub stylet/tube changer, LMA as intubating
    conduit, light wand, retrograde, trach

14
DIFFICULT AIRWAY ALGORITHM REVIEW
  • Whats your back up plan?
  • DIFFICULT VENTILATION
  • Combitube
  • LMA
  • Oral and nasopharyngeal airways
  • Rigid ventilating bronchoscope
  • Invasive access
  • Transtracheal jet ventilation
  • Two-person mask ventilation

15
DIFFICULT AIRWAY ALGORITHM REVIEW
  • WHATS YOUR BACKUP?
  • Remember
  • The uncooperative or pediatric patient may
    restrict your options
  • Although local or regional may be used, still
    need to have airway management backup plan!

16
DIFFICULT AIRWAY ALGORITHM REVIEW
  • Use ETCO2 to confirm placement
  • FOLLOW-UP
  • Document-include presence nature
  • What techniques were employed
  • Inform pt/responsible person personally
  • Consider letter to pt, recommend notification
    bracelet, flag the chart

17
DIFFICULT AIRWAY ALGORITHM REVIEW
  • The pt should be evaluation postop for possible
    complications.
  • Airway edema
  • Bleeding
  • Tracheal/esophageal perforation
  • Pneumothorax
  • aspiration

18
DIFFICULT AIRWAY RECOGNIZED
  • Preparing the patient for awake intubation
  • Psychological support
  • Antisialogue
  • Sedative
  • Mucosal vasoconstrictor
  • Local anesthetic for topical and nerve blocks

19
DIFFICULT AIRWAYRECOGNIZED
  • Choices for awake intubation
  • FOB
  • DL
  • Blind oro/nasotracheal
  • Retrograde
  • Illuminated stylet
  • Rigid bronchoscope
  • Percutaneous tracheal entry device

20
DIFFICULT AIRWAYRECOGNIZED
  • FAILURE TO INTUBATE
  • Cancel the case
  • Regional
  • If case is short can be terminated if necessary
  • If airway remains easily accessible
  • Surgical airway
  • Induce GA
  • If failure is b/o uncooperative pat.
  • Maintain spontaneous vent

21
DIFFICULT AIRWAYUNRECOGNIZED,CAN VENTILATE
  • ALWAYS CALL FOR HELP!
  • Induction has occurred, pt is paralyzed
  • Can ventilate with mask
  • 2 people may be better than 1 if borderline
  • May need oral and nasopharyngeal airways

22
DIFFICULT AIRWAY UNRECOGNIZED CAN VENTILATE
  • BEST ATTEMPT
  • Experienced laryngologist
  • Sniffing position
  • Ramp the obese
  • Use OELM
  • Length/size blade change once
  • Remember each attempt increases risk for airway
    trauma, bleeding, edema, and secretions

23
DIFFICULT AIRWAY, UNRECOGNIZED CAN VENTILATE
  • OTHER INTUBATION CHOICES
  • FOBblind oro/nasotracheal
  • Retrograde
  • Lighted stylette
  • Rigid bronchoscope
  • Percutaneous technique
  • REMEMBER VENTILATE THE PATIENT BETWEEN ATTEMPTS.

24
DIFFICULT AIRWAY, UNRECOGNIZED, CAN VENTILATE
  • CANT INTUBATE
  • Awaken the patient, follow the recognized
    pathway
  • Mask/LMA
  • Pt has no risk of aspiration
  • Appropriate for surgery
  • Surgical airway

25
DIFFICULT AIRWAY, UNRECOGNIZED, CAN VENTILATE
  • Extubate only when fully awake, spontaneous
    breathing, full recovery from muscle relaxants
  • Consider steroids to dec airway edema
  • Consider B2 agonist (inhaled) to dec bronchospasm
  • May want to extubate over jet-vent stylette/tube
    changer

26
CANT VENTILATE, CANT INTUBATE
  • Imminently life threatening rare
  • 0.01-2/10,000
  • FALLBACK OPTIONS
  • LMA
  • COMBITUBE
  • TRANSTRACHEAL JET VENTILATION

27
CANT VENTILATE, CANT INTUBATE
  • fallback should be chosen according to
    situation
  • LMA Combitube will not solve issue at/below the
    glottis (spasm, edema,k tumor, abscess, hematoma)
  • Transtracheal Jet Ventilation requires special
    technique to be effective

28
TRANSTRACHEAL JET VENTILATION
  • Insert 14-16 ga IV cath thru cricothyroid
    membrane in caudad direction
  • Confirm by aspirating free air
  • Continuously hold cath at skin line
  • Decrease 50-psi wall pressure to 30psi
  • Use 0.5 sec inspir time
  • Have 2nd person to provide jaw thrust, airway
    placement
  • Sanghvi,et al 2000

29
CANT VENTILATE, CANT INTUBATE
  • Consider awakening pt if able to ventilate via
    mask
  • Emergency surgical airway
  • FOLLOWUP
  • Detailed note in chart
  • Letter for patient
  • Counsel patient advise for MedAlert bracelet

30
AWAKE FOB GUIDED INTUBATION
  • Consider this approach when
  • Neck cannot be manipulated
  • Not possible to visual cords
  • KEY POINTS
  • Adequate planning
  • Adequate patient preparation

31
AWAKE FOB GUIDED INTUBATION
  • Chin lift and jaw thrust move soft tissues
    forward to facilitate procedure
  • Position is not a factor
  • Operator may stand at head of bed or at side
  • Glyco 0.2mg IM 1 hr prior/IV 10 min prior
  • Blood and secretions are the enemy of good
    visualization!

32
FOB GUIDED ENDOTRACHEAL INTUBATION
  • The more the airway is manipulated, the greater
    the chance of edema/bld/secretions
  • The goal of sedation is cooperation
  • May use fentanyl/midazolam/propofol, titrated to
    slurred speech, not unconsciousness

33
AWAKE FOB GUIDED INTUBATION
  • Topicalize the entire airway, nose mouth to
    bronchus
  • Vasoconstrictor to the nasal passages
  • Be aware that the topicalized airway inc the risk
    of aspiration in some patients!
  • Oral topical 4 lido viscous/spray/neb
  • Neb will help topicalize below the cords.

34
AWAKE FOB GUIDED ENDOTRACHEAL INTUBATION
  • Transtracheal block (3cc 2 Lido, 23Ga needle,
    thru the cricothyroid membrane)
  • Superior laryngeal nerve block (2.5 cc 1 Lido,
    23Ga needle walk off the hyoid inferiorly,
    aspirate, inject repeat on the opposite side)

35
AWAKE FOB GUIDED ENDOTRACHEAL INTUBATION
  • Nasal 7.0 ETT, well lubed, warmed in NS
  • Oral use the special airway well lubed
  • The ETT is passed between the cords during
    inspiration
  • Confirmation of tracheal placement is verified by
    the operator and ETCO2
  • Induction proceeds

36
AWAKE FOB GUIDED ENDOTRACHEAL INTUBATION
  • Videos showing the blocks can be seen at
  • http//www.gasnet.org/gta/chapters/fiber-intubatio
    n_br.php

37
THE DIFFICULT AIRWAY
  • KNOW YOUR BASICS
  • GET HELP
  • DONT PANIC
  • PAY ATTENTION
  • Thank you.
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