Case Discussion and Paper Reading

1

• Case Discussion and Paper Reading
• Topic Difficult Airway
• Intern ??? 2008 5/07

2
Case presentation

• A 72-year-old male was admitted via ER because of
  persistent jaundice for 3 days.
• And Common bile duct malignant tumor was
  diagnosed.
• He was then transferred to our GS ward to accept
  Whipple operation.

3
Post-Op day 1

• Mild fever and much sputum were noted.
• Throat pain was also complained.
• Assessment and management
• 1.fever may be caused by atelectasis
• 2.throat pain was common due to intubation
• 3.chest care was performed
• 4.bromhexine and half saline inhalation were
  prescribed.

4
Post-Op day 2

• 1000 pm, his family called the nursing staff due
  to irritable and tachypnea.
• 1100 pm, his family requested the nursing staff
  to performed suction due to much sputum and
  severe dyspnea.
• Cyanosis happened when suction was performed.
• ?CPR

5
CPR period

• The first time endotracheal intubation
• --- failed

6
CPR period

• The second time --- failed

7
CPR period

• The three times was finally success by the
  anesthesiologist.
• The totally CPR time was about 30 minutes.

8
Legal problem so sad !
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
If I have one more chance ?

• Delay extubation
• More invasive chest care
• Steroid use for laryngeal swelling

16

The difficult airway in adults

• Reference UpToDate 2007

17
Incidence of difficult intubation

• Although one review estimated the incidence of
  difficult ED intubation at 30 percent, variations
  in clinician expertise and experience greatly
  influence the subjective impression of intubation
  difficulty

18
Cormack-Lehane system

• Difficulty of direct laryngoscopy correlates with
  the best view of the glottis, as defined by the
  Cormack-Lehane scale

19
Cormack-Lehane system
Grade one a full view of the entire glottic
aperture, Grade three visualization of the
epiglottis only
20
How to evaluate difficult airway ?

• The LEMON approach to difficult airway assessment
  
• 1. L Look externally
• 2. E Evaluate (3-3-2 rule)
• 3. M Mallampati
• 4. O Obstruction
• 5. N Neck mobility

21
How to evaluate difficult airway ?

• The LEMON approach to difficult airway assessment
  
• 1. L Look externally
• 2. E Evaluate (3-3-2 rule)
• 3. M Mallampati
• 4. O Obstruction
• 5. N Neck mobility

22
L Look externally

• The clinician's general impression the airway
  will be difficult.
• Does the patient have abnormal face, unusual
  anatomy, or significant obesity, any of which can
  be expected to create difficulty ?

23
How to evaluate difficult airway ?

• The LEMON approach to difficult airway assessment
  
• 1. L Look externally
• 2. E Evaluate (3-3-2 rule)
• 3. M Mallampati
• 4. O Obstruction
• 5. N Neck mobility

24
E Evaluate (3-3-2 rule)

• The relationship between the size of the
  mandible, the distance between the mentum and the
  hyoid bone, and the extent of mouth opening
• All important geometric determinants of the
  success of direct laryngoscopy

25
3-3-2 rule

• Normal patient can open his mouth sufficiently to
  permit three of his own fingers to be placed
  between the incisors.
• Adequate mouth opening facilitates both insertion
  of the laryngoscope and obtaining a direct view
  of the glottis.

26
3-3-2 rule

• A normal patient is able to place three of his
  fingers between the mentum and the the hyoid
  bone.
• Adequate mandibular size is necessary to allow
  full displacement of the tongue into the
  submandibular space, permitting visualization of
  the glottis

27
3-3-2 rule

• A normal patient is able to place two fingers in
  the superior laryngeal notch (ie, the space
  between the superior notch of the thyroid
  cartilage and the hyoid bone.
• If the larynx is too high in the neck, direct
  laryngoscopy is difficult, because of the angles
  that have to be negotiated to permit
  visualization.

28
How to evaluate difficult airway ?

• The LEMON approach to difficult airway assessment
  
• 1. L Look externally
• 2. E Evaluate (3-3-2 rule)
• 3. M Mallampati
• 4. O Obstruction
• 5. N Neck mobility

29
Mallampati classification

• The Mallampati classification is a simple scoring
  system to help predict difficult intubation.
• The Mallampati class, ranging from I to IV,
  relates the amount of mouth opening to the size
  of the tongue, and provides an estimate of space
  for oral intubation by direct laryngoscopy.

30
Mallampati classification

• Class I or II predicts easy laryngoscopy,
• Class III predicts difficulty, and Class IV
  predicts extreme difficulty.

31
How to evaluate difficult airway ?

• The LEMON approach to difficult airway assessment
  
• 1. L Look externally
• 2. E Evaluate (3-3-2 rule)
• 3. M Mallampati
• 4. O Obstruction
• 5. N Neck mobility

32
O Obstruction

• The presence of upper airway obstruction
  interferes with both laryngoscopy and intubation.
  Supraglottic mass or infection, trauma with
  hematoma can obstruct the view of the glottis,
  block access for tube insertion by narrowing the
  airway.

33
(No Transcript)
34
How to evaluate difficult airway ?

• The LEMON approach to difficult airway assessment
  
• 1. L Look externally
• 2. E Evaluate (3-3-2 rule)
• 3. M Mallampati
• 4. O Obstruction
• 5. N Neck mobility

35
N Neck mobility

• Ideally, the patient is placed in the sniffing
  position for intubation. The sniffing position is
  achieved by flexing the neck forward on the body
  (thoracic spine) then extending the head on the
  neck (atlanto-occipital joint)
• It is controversial whether a superior
  laryngoscopic view is obtained by the sniffing
  position versus simple neck extension, but there
  is no question that extension of the head on the
  neck is a key aid in obtaining a glottic view by
  direct laryngoscopy.

36
N Neck mobility

• Decreased cervical spine mobility, specifically
  limitation of extension of the head on the neck,
  compromises the laryngoscopic view.
• Medical conditions, such as psoriatic or
  rheumatoid arthritis, or ankylosing spondylitis,
  or simply the degenerative joint disease that
  accompanies aging, can greatly reduce neck
  mobility.

37
Difficult BMV evaluation--MOANS

• Mask seal
• Obesity
• Age gt55
• No teeth (Edentulousness)
• Stiffness

38
Difficult BMV evaluation--MOANS

• Mask seal
• Obesity
• Age gt55
• No teeth (Edentulousness)
• Stiffness

39
Mask seal

• Mask seal requires reasonably normal anatomy,
  absence of facial hair, lack of interfering
  substances, such as excessive vomitus or
  bleeding, and the ability to apply pressure to
  the face with the mask.

40
Difficult BMV evaluation--MOANS

• Mask seal
• Obesity
• Age gt55
• No teeth (Edentulousness)
• Stiffness

41
Obesity

• Obesity is an independent marker of difficult
  BMV.
• Redundant upper airway tissue and the combination
  of chest wall weight and resistance from
  abdominal contents all impede airflow.
• Late third trimester pregnancy is a surrogate for
  obesity with respect to BMV, as it creates many
  of the same problems.

42
Difficult BMV evaluation--MOANS

• Mask seal
• Obesity
• Age gt55
• No teeth (Edentulousness)
• Stiffness

43
Age gt55

• Age gt55 years is a marker of difficult BMV.
• Most likely the general loss of elasticity of
  tissues and the increased incidence of
  restrictive or obstructive pulmonary disease make
  ventilation more difficult.

44
Difficult BMV evaluation--MOANS

• Mask seal
• Obesity
• Age gt55
• No teeth (Edentulousness)
• Stiffness

45
No teeth (Edentulousness)

• No teeth (Edentulousness) creates difficulty with
  BMV.
• Teeth provide a framework against which the mask
  sits and support the cheeks, enhancing mask seal.
  
• If a patient has dentures, they should be left in
  situ during BMV, where they are of benefit, then
  removed for direct laryngoscopy, where they are
  detrimental.

46
Difficult BMV evaluation--MOANS

• Mask seal
• Obesity
• Age gt55
• No teeth (Edentulousness)
• Stiffness

47
Stiffness

• Stiffness, with respect to BMV, refers to
  conditions that make the lungs "stiff" or
  resistant to ventilation, and include asthma,
  chronic obstructive pulmonary disease (COPD),
  pulmonary edema, widespread infiltrates, and any
  other conditions that decrease pulmonary
  compliance.

48

• Thanks for your attention!