Preoperative planning of airway management

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Preoperative planning of airway management

• ?? R1???
• ????CR???
• ???????

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Brief history

• ?x?
• 52 y/o,Male
• Chief complainHoarseness for 4 months

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Brief history

• Hoarseness since 4 months ago
• Chocking,odynophagia,dysphagia,and blood-tinged
  sputum were noted
• Laryngoscopelaryngeal tumor with vocal cord
  fixation

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Brief history

• Past history denied any systemic disease like
  DM,HTN,CAD
• OP historydenied
• Allergy historydenied
• Smoke2ppd for 30ys
• Betel nut10pd for 30ys
• Alcohol1bt pd(?????)for 10ys

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Brief history

• PEno specific finding except left neck mass
• Local finding

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Brief history
RBC 4.42104/uL AST 26
Hb 13.1g/dL ALT 18
Hct 40.5 ALP 175
MCV 91.6fL BUN 11.8
Plt 365 103/uL Cre 0.9
WBC 10940 103/uL Na 136
PT 12.4 K 4.1
PTT 32.7 Cl 101
INR 1.11

• Lab data

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Brief history

• Laryngoscope finding

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• Impression laryngeal tumor
• PlanLMS and tumor biopsy

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Pre-operation

• Vital signT/P/R36.5/82/20, BP128/83
• ASA class II
• Induction and intubation

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Induction
800

• Intubation-failure

• HR83
• BP142/80
• SpO299
• Induction
• Propofol 10ml
• SCC80mg
• Solumedral 1amp
• Xylocain3ml

Mask ventilation-failure
SpO2-gt20 BP200/110 HR110
Fiberoptic -bloody secretion
Mask ventilation-failure
815
Sevoflurane Atropine0.5ml
Mask ventilation-OK
Fibroscope intubation
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The questions

• How to preoperative planning of airway
  management?
• How to management unanticipated difficult airway
  ?
• What happened in our patient?
• Could we do better?

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Preoperative planning of airway management

• Airway approach algorithm(AAA)
• Used before induction
• Choose an appropriate DAA root point
• Avoid emergency pathway branches of DAA

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Conditions associated with difficult intubations

• Tumorscystic hygroma,hemangioma,hematoma
• Infectionssubmandibular abscess
• Congenital anomaliesPierre Robin syndrome

• Foreign body
• Traumalaryngeal fracture,C spine injury
• Obesity
• Inadequate neck extensionRA,AS
• Anatomic variationsmicrognathia,prognathism

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Airway approach algorithm(AAA)

• Is airway management necessary?
• Will direct laryngoscopy and tracheal intubation
  be straightforward?
• Can supralaryngeal ventilation be used?
• Is there an aspiration risk?
• In the event of airway failure, will the patient
  tolerate an apneic period?

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Q1 Is airway management necessary?

• Is GA required for surgical procedure at hand?
• Regional anesthesia and local infiltration and
  invasive procedures may all required airway
  manipulation or conversion to a GA

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Evaluation of the airway

• Patients history
• submandibular trauma,radiation,surgery
• Physical evaluation
• 1.mouth opening(interincisor gap)4-cm gap
• 2.oropharyngeal score(Mallampatti score)
• 3.thyromental distancegtorlt6cm
• 4.chin protrusion
• Additional evaluation

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• Difficult to evaluate on routine the preoperation
  exam
• 1 thyromental spacepathologic factors
• 2 lingular tonsil hyperplasia(indirect
  fiberoptic or mirror examination)
• 3 chipped or broken teeth
• 4 postop dysphonea,sore throat,TMJ pain,
  tracheal intubation history,time

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Thyromental space

• 1line of sight
• 2teeth
• 3oral and pharyngeal axes and cavities
• 4tongue
• 5larynx
• 6laryngoscope

• Sup.mentum
• Inf.hyoid bone
• Lat.neck

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Q2Is there potential for a difficult
laryngoscopy? NO -gt
Failed tracheal intubation should be
inconsequential if ventilation may be achieved
by other means
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Q3Can supralaryngeal ventilation be used?

• Predictors for difficult face mask ventilation
• 1.body mass index gt26
• 2.agegt56 yrs
• 3.edentulous
• 4.history of snoring
• 5.facial hair

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LMA failure

• Oral and pharyneal axes
• Space-occupying lesions in the hypopharynx
• Lesions below the hypopharynx (including high
  airway pressure)
• Tracheal thrombosis,tracheal stenosis,laryngeal
  ca,Hunter syndrome,obstetrial patient,severe
  RA,meconium aspiration

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• May err in ans Q2 or Q3, resulting in
  unnecessarily under taking awake intubation, but
  the error is made in favor of patient safety
• It would be foolhardy to induce anesthesia in a
  patient you were not sure you could intubate or
  ventilate by any means

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Q4Is the stomach empty?(Is there an aspiration
risk?)

• Nonfasted patientSevere,poorly controlled reflux
• Should not be ventilated by supralaryngeal means
• Tracheal protectioncombitube,classic
  LMA,proseal-LMA
• Equivalent of cannot inbubate and should not
  ventilate ?Awake intubation

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Q5Will the patient tolerate an apnic period?

• Healthy adult5-9 min after onset of apnea
• Factorsobesity,pregnancy,illness,inadequate
  preoxygenation
• Thiopental 30-60secspropofolgt60secs
• SCC4-7mins

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What happened in our patient?

• Upper airway obstruction? Not like, because
  preoxygenation was well.
• Laryngospasm? Moor like, because when we deepen
  the anesthetic level the ventilation was sucessed

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Laryngospasm

• Most caused by irritative stimulus to airway
  during a light plane of anesthesia
• Noxious stimulisecretions,vomitus,blood,inhalatio
  n of pungent volatile anesthetics,oropharyngeal
  or nasopharyngeal airway,laryngoscopy,peripheral
  stimuli

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Laryngospasm

• Deepening the anesthetic level
• Removing the stimulus(suction,withdrawal
  artificial airway)
• 100 oxygen
• Continuous positive pressure on the airway
• Small dose of S.C.C(10-20mg IV)
• Application of digital pressure at the
  laryngospasm notch

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What can we do better?

• History and physical examination
• Before induction , think about the five Qs
• Choose the right DAA rout
• Consider use of LMA if the patient do not have
  the unsafe factors
• Use suction or SCC if laryngospasm

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References

• William H. Rosenblatt, MDPreoperative planning
  of airway management in critical care patients.
  Crit Care Med 200432186-192
• Practice guidelines for management of the
  difficult airwayan updated report by the
  American Society of Anesthesiologists Task Force
  on Management of the Difficult Air-way,Anesthesiol
  ogy 2003981269-1277
• Clinical anesthesia procedures of the
  Massachusetts general hospital 6th edition P288
• J.J.Henderson,M.T. Popat,I.P. Latto and A.C.
  Pearcedifficult airway society guidelines for
  management of the unanticipated difficult
  intubation. Anaesthesia,200459675-694
• Clinical anesthesiology 3rd P71-83