Title: Case discussion A case of difficult intubation
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2Case discussionA case of difficult intubation
-
- Intern ???
- Department of anesthesiology
- NTUH
2001/12/25
3Brief history (1)
- Name?X? Chart No4099581
- Sex/Agemale , 59 y/o Bed No9D-13-1
- Admission date2001/12/4
- Past History 1.DM , fresh case
- 2.denied other systemic
disease - 3.smoking and drinking when
young - 4.denied any food and drug
allergy - 5.no recent travel and
trauma history
4Brief history (2)
- Posterior neck swelling without discharge
initially since 11/19. - He visited our ER for discharge and tenderness of
the wound on 11/29. - Low grade fever,leukocytosis and high CRP value
were noted. - Unasyn,Metronidazole and Gentamicin were given
with only minor improvement of lab data and
clinical condition. - He was discharge under cellulitis and suggested
OPD F/U. - Because of purulent discharge persisted,the
patient visited our ER again on 12/4. - Deep neck infection was suspected ,he was
admitted for further care and op evaluation.
5Brief history (3)
- PE erythematous induration all over the
posterior neck region mild tenderness. - CXR shows normal heart size with slightly
increased lung markings. Tortuous aorta is noted.
- SPINE CERVICAL AP. LAT showed marked
degenerative change of C-spine with calcification
of post. nuchal ligament. post. spur are noted at
C5 6 7.
6Brief history (4)
- Neck CT without/with contrast enhancement shows
- 1. soft tissue swelling with low density change
at dorsal aspect of neck and occpital region
symmetrically, the fat planes are blurred. there
is indistinct interface of the swollen soft
tissue with the posterior neck muscles (splenius
capitus and probably semispinalis). infectious
process is considered, probably cellulitis and
myositis. - 2. the spine is intact
- 3. no abnormal enlarged LAPs
7Brief history (5)
- Pre op 59 y/o male with DM was diagnosed neck
abscess s/p ID. - Op methodDebridement on 12/7
- ASA class III
- Neck movement decrease,extension(-)
- short neck , small mandible
- Risk of difficult intubation was explained to
family.
8Anesthesia course (see record)
- Induction of general anesthesia followed by
direct laryngoscopy and oral intubation. - -gt difficult intubation
- -gt Flexible fiberoptic intubation
- --gt IVG propofol infusion
9Prediction and Management of Difficult Tracheal
Intubation
- Introduction
- Predicting Difficult Intubation
- Preparation for Intubation
- Planning Anaesthesia
10Introduction
- During routine anaesthesia the incidence of
difficult tracheal intubation has been estimated
at 3-18. - Class I the vocal cords are visible
- Class II the vocals cords are only partly
visible - Class III only the epiglottis is seen
- Class IV the epiglottis cannot be seen.
- Cormack RS, Lehane J. "Difficult intubation
- in obstetrics." Anaesthesia 1984391105-11
11Predicting Difficult Intubation (1)
- "sniffing the morning air" position
- History and examination
- Specific Screening Tests to Predict Difficult
Intubation. - View obtained during Mallampati test
- 1. Faucial pillars, soft palate and uvula
visualised - 2. Faucial pillars and soft palate visualised,
but uvula - masked by the base of the tongue
- 3. Only soft palate visualised
- 4. Soft palate not seen.
- Samsoon GLT, Young JRB. "Difficult tracheal
- intubation a retrospective study."
- Anaesthesia 198742487-90
12Predicting Difficult Intubation (2)
- Thyromental distance
- Grade 3 or 4 Mallampati who also had a
thyromental distance of less than 7cm were likely
to present difficulty with intubation - Frerk CM. "Predicting difficult intubation."
Anaesthesia 1991461005-8 - Sternomental distance
- A sternomental distance of 12.5cm or less
predicted difficult intubation - Savva D. "Prediction of difficult tracheal
intubation." British Journal of Anaesthesia
199473149-53
13Predicting Difficult Intubation (3)
- Protrusion of the mandible
- If the patient cannot get the upper and lower
incisors into alignment intubation is likely to
be difficult. - Calder I, Calder J, Crockard HA. "Difficult
direct laryngoscopy in patients witH cervical
spine disease." Anaesthesia 199550756-63 - X-ray studies
- Various studies have been used to try to predict
difficult intubation by assessing the anatomy of
the mandible on X-ray. These have shown that the
depth of the mandible may be important, but they
are not commonly used as a screening test.
14Preoperative assessment
- A combination of the above tests is better than
using only one. The modified Mallampati,
thyromental distance, ability to protrude the
mandible and craniocervical movement are probably
the most reliable.
15Preparation for Intubation (1)
- Anaesthetists should be ready to deal with
difficulties in intubation at any time. The
correct equipment must be immediately available.
This will include - laryngoscopes with a selection of blades
- a variety of endotracheal tubes
- introducers for endotracheal tubes (stylets or
better, flexible bougies) - oral and nasal airways
16Preparation for Intubation (2)
- a cricothyroid puncture kit (a 14 gauge cannula
and jet insufflation with high pressure oxygen is
the simplest and cheapest kit - reliable suction equipment
- a trained assistant
- laryngeal mask airways, sizes 3 4
17After intubation
- The anaesthetist should ensure that the patient
is in the optimal position for intubation and
must be able to oxygenate the patient at all
times. - After intubation correct placement of the tube
should be confirmed by - a stethoscope listening over both lung fields in
the axillae - observing the tube pass through the cords
- successful inflation of the chest on manual
ventilation
18Special techniques for intubation
- Awake intubation under local anaesthesia
- Oral intubation
- Nasal intubation is the best method of awake
intubation using a fibreoptic bronchoscope or
other intubating fibrescope via the nose.
19Retrograde intubation (1)
- is a technique first described in Nigeria
- Waters DJ "Guided blind endotracheal intubation
for patients with deformities of the upper
airway." Anaesthesia 196318158-62 - Retrograde intubation has recently been used
successfully for traumatised airways when
conventional techniques had failed - Barriot P, Riou B. "Retrograde technique for
tracheal intubation in trauma patients."Critical
Care Medicine. 198816712-3 -
- the membrane between the cricoid and first
tracheal ring can also been used. - Shanther TR. "Retrograde intubation using the
subcricoid region." British Journal of - Anaesthesia. 199268109-12
20Retrograde intubation (2)
21The Laryngeal Mask Airway
- is a common device in anaesthesia and can often
provide a good airway in patients in whom
intubation is difficult. Following insertion the
anaesthetist may use it to maintain the airway
during anaesthesia, or may use it as a route to
allow tracheal intubation.
22The McCoy laryngoscope
- is designed with a movable tip which allows the
epiglottis to be lifted and intubation often made
easier - McCoy EP, Mirakhur RK. "The levering
laryngoscope." Anaesthesia 199348516-9
23- A light wand is a long flexible device which has
a bright light at the end and can be directed
into the trachea with an endotracheal tube
mounted over it - Robelen GT, Shulman MS. "Use of the lighted
stylet for difficult intubations in adult
patients (abstract)." Anesthesiology 198971A439
- The Combi-tube is a tube which may be inserted
blindly and used to ventilate the patient in an
emergency - Frass M, Frenzer R. Zahler J, Lilas W, Leithner
C. "Ventilation via the esophageal tracheal
combitube in a case of difficult intubation."
Journal of Cardiothoracic Anaesthesia
19871565-8
24Planning Anaesthesia
- During general anaesthesia patients must never be
given muscle relaxants unless the anaesthetist
can be certain of being able to ventilate them. - When the anaesthetist faces unexpected difficulty
in intubation the priority is to ensure adequate
mask ventilation and oxygenation of the patient. - Multiple attempts at endotracheal intubation may
result in bleeding and oedema of the upper airway
making the task even more difficult. Often it is
better to accept failure after a few attempts and
move on to a pre-planned failed intubation
sequence - King TA, Adams AP. "Failed tracheal intubation."
British Journal of Anaesthesia199065400-414
25Failed intubation
- If intubation proves impossible the anaesthetist
should consider whether to allow the patient to
wake up and carry on surgery with regional
anaesthesia, or whether to abandon the surgery
altogether. In situations where surgery is of an
urgent nature it may be prudent to carry on the
general anaesthetic under face mask anaesthesia
if the airway is easy to maintain. - If the airway is impossible to maintain and the
patient is becoming hypoxic, an emergency
cricothyroidotomy is required. If time allows an
emergency tracheostomy can be considered.
26Difficult airway algorithm (ASA)
- Practice guidelines for management of the
difficult airway. A report by the American
Society of Anesthesiologists Task Force on
Management of the Difficult Airway.
Anesthesiology. 1993 Mar78(3)597-602.
27ASA Algorithm Part 1
28ASA Algorithm Part 2
29Awake Intubation Pathway
30- Non-surgical techniques for awake intubation
include laryngoscopy, fiberoptic bronchoscopy and
retrograde intubation. Surgical access may be
secured by awake tracheostomy. - Awake intubation requires patient cooperation and
should be performed with local anesthesia. See
Local Anesthesia for more information. - If awake intubation efforts fail, the patient is
unlikely to have compromised ventilation.
Consider canceling the case, other intubation
options or surgical access to the airway.
31Intubation After Induction Pathway
32- After induction of anesthesia, if the initial
intubation attempts are unsuccessful, consider
returning to spontaneous ventilation, awakening
the patient and calling for help. - If mask ventilation is adequate, go to the
Non-Emergency Pathway. If mask ventilation is
inadequate go to the Emergency Pathway. - If mask ventilation becomes inadequate at any
time while following the Non-Emergency Pathway,
go to the Emergency Pathway
33Non-Emergency Pathway
34- Follow the Non-Emergency Pathway when the patient
is anesthetized, intubation is unsuccessful and
mask ventilation is adequate. If mask ventilation
becomes inadequate go directly to the Emergency
Pathway. - Consider alternative approaches including
fiberoptic intubation, intubation stylet, blind
intubation, light wand and retrograde intubation. - If failure after multiple attempts, consider
awakening the patient, surgical airway or surgery
under mask anesthesia.
35Emergency Pathway
36- Follow the Emergency Pathway when the patient is
anesthetized, intubation is unsuccessful and mask
ventilation is inadequate. - Time is critical. Call for help. Do one more
intubation attempt or emergency non-surgical
airway ventilation or emergency surgical airway. - Do not continue to attempt a previous
unsuccessful technique. - Emergency non-surgical airway ventilation
techniques include transtracheal jet
ventilation, intratracheal jet stylet, laryngeal
mask, oral and nasopharyngeal airways, two person
mask ventilation, and rigid ventilating
bronchoscope. - Emergency non-surgical airway ventilation
techniques are temporizing measures. Establish a
definitive airway as soon as possible.
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41Thanks for your attention!!