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Difficult Airway Management

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Difficult Airway Management Anesthesia Assistant Course Algonquin College Joel Berube 19 SEP 09 – PowerPoint PPT presentation

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Title: Difficult Airway Management


1
Difficult Airway Management
  • Anesthesia Assistant Course
  • Algonquin College
  • Joel Berube
  • 19 SEP 09

2
Objectives
  • Airway management is our specialty!
  • Significant MM associated with mismanaged
    airways
  • Avoidance
  • Anticipate
  • Airway exam, predictors of difficulties
  • Preparation
  • Know your equipment
  • Back-up plan
  • Methods, adjuncts for intubation/ventilation/oxyge
    nation

3
Outline
  • The Difficult Airway
  • Definitions
  • Assessment
  • The Algorithm
  • Anticipated DA
  • Unanticipated DA
  • Devices
  • Fibreoptic Bronch
  • Glidescope
  • Bullard Scope
  • Jet Ventilator
  • Surgical Airways
  • Percutaneous Trach
  • Cricothyroidotomy
  • Trans-tracheal Jet

4
The Difficult Airway Definitions
  • Difficult Airway
  • Difficult Laryngoscopy
  • Difficult Mask Ventilation
  • Difficult Endotracheal Intubation

5
Difficult Airway
  • Situation where a conventionally trained
    anesthesiologist experiences difficulty with
    mask ventilation, endotracheal intubation or both

6
Difficult Mask Ventilation
  • 1 person unable to keep SpO2 gt92
  • Significant gas leak around face mask
  • No chest movement
  • Two-handed mask ventilation needed
  • Change of operator required
  • Use of fresh gas flow button gt2X (flush)

7
Predictors of Difficult Ventilation
  • Beard
  • Hiding? Bad seal
  • Obesity
  • BMI gt 26
  • Age
  • gt55
  • Teeth
  • Lack of
  • Snoring
  • On history or dx OSA

BOATS
8
Difficult Laryngoscopy
  • Not possible to view any part of the vocal cords
    during direct laryngoscopy
  • Cormac-Lehane Grades III/IV

9
Difficult Endotracheal Intubation
  • Insertion of ETT with direct laryngoscopy
    requires gt3 attempts or gt10 minutes
  • Or when an experienced laryngoscopist using
    direct laryngoscopy requires
  • More than 2 attempts with same blade
  • Change in blade or use of adjunct
  • Use of alternative device/technique following
    failed intubation with direct laryngoscope

10
Predictors of Difficult Laryngoscopy/Intubation
  • aka your airway assessment (last class)
  • Mallampati
  • What can you see when they open their mouth?
  • Mouth Opening, teeth
  • Can you fit your blade tube in the opening?
  • Thyromental Distance
  • Predicts an anterior larynx
  • C-Spine Range of Motion
  • Can they get in a sniffing position?

11
Tough Airways?
12
General Approach to Airways
  • Is Airway Control Required?
  • ie is there a different anesthetic technique?
  • Predict Difficult Laryngoscopy?
  • Is Supralaryngeal Ventilation (LMA, mask) ok to
    use if needed?
  • ie can you get away without intubation?
  • Full Stomach?
  • Will the patient tolerate an apneic period?

13
Difficult Airway Algorithm
  • A model for the approach to the difficult airway
  • Considers
  • Patient factors
  • Clinical setting
  • Skills of the practitioner
  • If you need to intubate the patient for the case
    and run into trouble at any step

14
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15
Airway assessment
  • Non-Reassuring
  • Laryngoscopy
  • Ventilation technique
  • Aspiration Risk
  • Intolerance of apnea
  • Anticipated DA
  • Awake Technique
  • Box A
  • NB - Invasive knife or needle in the neck
    (see surgical airway)
  • Reassuring
  • Put the patient to sleep, now having difficulty
  • Unanticipated DA
  • Attempts after induction
  • Box B

16
Difficult Airway Algorithm - Anticipated DA
17
DA anticipated, intubate Awake
  • Patient will maintain their own patent airway
  • Can abandon or try another approach
  • No bridges burned
  • Concept freeze the airway, put the tube in, /-
    sedation (usually !)

18
Awake Intubation Advantages
  • Maintain spontaneous ventilation
  • Wide open pharynx and palate space
  • Forward tongue
  • Maintain esophageal tone (?aspiration)
  • Able to protect if reflux occurs
  • Risk of neurologic injury able to monitor
    sensory-motor function
  • Some spines awake intubation positioning!

19
Contraindications to Awake
  • Emergency no ABSOLUTE, but caution
  • Cardiac ischemia, bronchospasm, increased ICP or
    ocular pressure
  • Elective
  • Refusal or inability to cooperate
  • Child, mental retardation, dementia, intox
  • Allergy to local anesthetics

20
Technique
  • Generally Awake Intubation implies use of
    Fibreoptic Bronchoscope
  • Any other method to intubate is possible, but
    likely more difficult or tough to tolerate
  • Used to do awake blind nasal intubations in
    trauma patients (some still do)

21
The Fibreoptic Bronchoscope
  • fragile device with optical and non-optical
    elements
  • Glass-fibre bundle (10k-30k fibres)
  • Objective - Insertion Cord - Eyepiece
  • 60cm, graduated q10cm
  • Flexible, rotate, bend, control
  • Working Channel (2mm diam)
  • Suction, O2, fluids, drugs
  • Peds intubating scopes no channel (lt2mm ext
    diam)
  • Light Source

22
Bronch
23
FOB intubation
  • Local Anesthetic
  • 3 areas to freeze
  • Nasopharynx
  • Base of tongue
  • Larynx/trachea
  • Topical
  • Swish/swallow
  • Pledgets
  • Viscous
  • Nebulized
  • 4 Lido, 10-15min pre
  • Nerve Blocks
  • Bronch
  • Correct size
  • Light Source
  • monitor/eyepiece
  • Suction
  • O2 for patient
  • Tube/Lube
  • Oral Airways/Bite block

24
FOB intubation
  • Topicalize the airway
  • Supplemental O2
  • Appropriate sedation
  • For the patient!
  • Insert Oral Airway
  • Appropriate size it will help guide scope and
    protect it
  • Tube loaded on scope
  • Holder/tape
  • suction
  • Visualize cords with scope
  • Some more local via working channel?
  • Advance ETT
  • Confirm placement
  • ETCO2
  • Induce the anesthetic
  • Very uncomfortable

Patient needs coaching/reassurance throughout!!!
25
Troubleshooting
  • Tube not advancing through cords
  • Too large tube and too small scope the extra
    room causes the tube to catch on arytenoids
  • Softer ETT
  • Deep breath
  • Scope in centre of cords, bevel forward, rotate
    ETT clockwise
  • FOB not good if pt. bleeding in A/W or
    secretions
  • Suction not adequate
  • Try O2 to clear lens
  • Desaturations
  • Keep O2 on!
  • Breaks for patient
  • Sedation level
  • Fogging up
  • Defogger
  • Warm scope prior to starting
  • Suction/insuffl/flush
  • Adjust picture?

26
Pearls
27
DA Algorithm
  • Ok, so if youre not reassured by the airway,
    intubate awake
  • If not successful (box A)
  • Cancel/wake vs. invasive airway!!
  • What if the airway doesnt look bad and you bang
    the patient off to sleep only to see this

Obviously you cant just stick the tube in! What
now?
28
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29
From this point on, consider
  • Call for Help
  • Absolutely!
  • Return to Spontaneous Ventilation
  • If you can
  • Awakening the patient
  • If you can

30
Cannot Intubate Scenario
  • Optimize position/scope etc
  • DO NOT persist with repeated attempts at direct
    laryngoscopy
  • Evidence that this approach leads to
    complications (including death)
  • Return to Mask Ventilation, get SpO2 back up and
    try another technique
  • Glidescope, Bullard, Bougie, Trachlite,
    Intubating LMA, McCoy Blade

31
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32
Alternate Techniques
  • Your first attempt at laryngoscopy should always
    be set up to be the best
  • Early transition from one technique to another
    without persistent and multiple failed attempts
  • On subsequent attempts, use adjuncts to enhance
    whatevers missing the last time
  • Need to remain fluid/flexible and adapt the plan
    as you progress through the algorithm
  • Often means going through lots of equipment
  • Having backups and backups for the backups

33
Other devices
  • Reviewed last week?
  • Different laryngoscope blades
  • MAC, Miller, McCoy
  • Different introducers
  • Stylet, Bougie, Trachlite
  • Supraglottic Devices
  • LMA, Proseal, Fastrach (ILMA)
  • Combitube, King Airway, Cobra Airway

34
Glidescope
  • Video-assisted laryngoscopy
  • Video chip set at the end of a conventional-like
    blade
  • Steeper angle (60º)

Canadian Invention!
35
Glidescope Advantages
  • Setup minimal/easy!
  • Handled with similar skills for direct
    laryngoscopy
  • But in midline
  • No need to elevate tongue
  • Point of sight is near blade tip
  • Can see around the corner
  • Image on screen
  • Supervisor, assistant can see too
  • Less stress on airway
  • Dont need external light source
  • Lightweight, compact

36
Glidescope Negatives
  • As with FOB, image can be obscured by
    blood/secretion
  • Less a problem with color vs. B/W monitor
  • Sometimes view is better than you can get a tube
    into
  • Variations on stylet bends
  • Re-usable glidescope stylet
  • Limited number of handles/blades
  • Need to be sterilized between uses
  • Cap in correct place before cleaning!!!

37
Bullard Scope
  • Fixed fibreoptic cable on posterior part of blade
  • Same setup as FOB
  • Eyepiece
  • Working Channel
  • Detachable Stylet
  • Blade has natural curve
  • Good if C-spine ROM ?

Predecessor to Glidescope?
38
Bullard s
  • Low profile
  • Gets into mouth when opening limited
  • High Flow O2 via channel blows secretions away
    and may reduce fogging
  • Attached stylet helps direct tube to glottis
  • Can use standard scope handle instead of light
    source

39
Bullard -s
  • Finnicky sometimes very difficult to get a good
    view, even in an easy airway
  • Plastic extension on blade sometimes dislodges.
    Dont forget it in the patient!!!

40
Back to the Difficult Airway
  • Still unable to intubate despite help, various
    adjuncts, adjustments, alternate devices
  • Now youre having trouble ventilating!!!
  • Now try 2 and 3 handed mask ventilation, LMA (if
    feasible)
  • If this works, get the SpO2 back up, breathe
    yourself Try again, abort, discuss

41
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42
Cannot Intubate-Cannot Ventilate
  • THIS IS AN EMERGENCY
  • If you havent yet CALL FOR HELP
  • People die if you cant ventilate them
  • You NEED to secure an airway or have the patient
    awake and breathing on their own!
  • Securing the airway likely now Invasive Airway
  • Salvage techniques while getting the surgical
    airway?

43
The Surgical Airway
  • aka the invasive airway
  • If access to the airway through the mouth or nose
    is unavailable, need to access the airway via the
    trachea
  • Needle cricothyroidotomy and jet ventilation
  • Percutaneous cricothyroidotomy set
  • Emergency/Awake Tracheostomy

44
Cricothyroidotomy
  • Landmarks thyroid cartilage, cricoid cartilage
    cricothyroid membrane
  • Local to skin (if time) and entry via membrane
    with large needle attached to partially-filled
    syringe
  • Aspiration of air into airway!
  • Proceed to ventilate, retrograde wire intubation,
    percutaneous cric set

45
Transtracheal Ventilation
  • Connect the needle/angiocath to an oxygen source,
    jet ventilator, ambubag and deliver air/oxygen
    into the trachea
  • Not a protected or definitive airway
  • Life-saving, temporizing measure

46
Sanders Jet Ventilation
  • O2 from hi-pressure source (50psi) thru valve and
    switch to a needle and into the airway
  • Used in shared airway surgeries
  • Rigid bronch

Surgeon working in airway, cant use normal
ventilation/ETT
47
Sanders Jet Ventilator
  • Continuous Ventilation is possible
  • Can minimize apneic period, shorten surgery
  • Can deliver O2, N2O, Volatile Anesthetic
  • Jet entrains room air, so variable and
    unpredictable FiO2 at end of scope
  • Inadequate ventilation of lungs if poor
    compliance
  • Difficult to assess adequacy of ventilation
  • Can be used for transtracheal oxygenation
  • Next section

48
Percutaneous Cric Set
  • Once cricothyroid membrane punctured with needle,
    can use Seldinger technique to dilate tissues and
    insert a large bore cannula to secure the airway
  • Not a trach, but allows ventilation and
    oxygenation with low-pressure systems (std 15mm
    connector)
  • Ambubag, conventional ventilator
  • Some are cuffed, so would protect airway

49
Emergency Tracheostomy
  • Rather than needling the neck, once its
    established that the patient needs a surgical
    airway, the surgeon performs a surgical
    tracheostomy
  • Awake or asleep, depending on where on the
    algorithm the scenario happens to be

50
Awake Tracheostomy
  • Some airways are so non-reassuring and patients
    so high risk that Plan A is to perform a
    tracheostomy under local anesthetic (/- minimal
    sedation) PRIOR to any other airway management or
    anesthesia
  • Ex certain head/neck tumors/malformations,
  • Any attempt at awake intubation may create an A/W
    obstruction and loss of airway
  • Cant intubate, cant ventilate scenario is
    avoided!
  • Awake patient prepped and draped, surgery
    started once airway access secured, induction of
    anesthesia can occur

51
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52
Recap
  • Difficult Airway Definitions
  • Predictors
  • Difficult Airway Algorithm
  • Fibreoptic Bronchoscope
  • Awake intubation
  • Alternate Devices
  • Glide, Bullard, Sanders
  • Emergency Airway
  • Surgical Airway

53
Take-Home messages
  • Not all airways are routine
  • Theres more to a difficult airway than difficult
    laryngoscopy
  • Need skills with various airway tools and
    adjuncts and must transition between them easily
    and quickly
  • Familiarity with the difficult airway algorithm
    should give you a sense of which direction a
    given scenario is taking
  • When faced with cannot intubate, cannot ventilate
    scenario, decision to secure surgical airway is
    life-saving and hesitation can be costly

54
Questions? Discussion?
  • Thank you.
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