Difficult Airway Management | Jindal Chest Clinic (1)

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DIFFICULT AIRWAY MANAGEMENT

• Tools and Tactics for Success

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First Case of the Day
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ASA Definition

• The Difficult Airway-
• is defined as the clinical situation in which a
  conventionally trained Anesthesiologist
  experiences difficulty with facemask ventilation
  of the upper airway, difficulty with tracheal
  intubation, or both
• Difficult to Ventilate-
• is when signs of inadequate ventilation could
  not be reversed by mask ventilation or oxygen
  saturation could not be maintained above 90
• Difficult to Intubate-
• is when a trained Anesthetist using
  conventional laryngoscope takes more than 3
  attempts

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DISCUSSION

• 4th National Audit Project NAP4
• Causes of difficult intubation
• Basic airway evaluation (Lemon Law )
• Airway Management A-B-C
• Gallery of tools
• Extubation of the Difficult Airway
• ASA Difficult airway algorithm

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Degrees of Airway Difficulty
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Overlap

• Difficult
• Mask
• Ventilation

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Overlap

• Difficult Mask Ventilation

Difficult SGA
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Triple Failure

• Difficult
• SGA

Difficult Mask Ventilation
Difficult Intubation
DANGER ZONE
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An Emergent Surgical Airway is Not Always Assured

• Difficult Mask Ventilation

Difficult surgical airway
Difficult Intubation
Danger Zone
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4th National Audit Project NAP4

• Sept 2008-Sept 2009 estimated 2,900,000 GA
  performed in the UK
• Data collected on 114,904 GAs from 309 hospitals
  over a 2 week period
• 184 serious airway complications, including
• -Death (14)
• -Brain Damage
• -Emergent Surgical Airway
• -Unexpected ICU admission

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NAP4 Lessons Learned

• PRIMARY PROBLEMS
• Aspiration 1
• Extubation Problems
• Tracheal Intubation
• Delayed Intubation
• Failed Intubation
• Cant Intubate Cant Ventilate

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NAP4 Lessons Learned

• Poor Airway Assessment Poor Planning
  contributed to Poor Outcomes
• Failure to match strategy to assessment
  (technique)
• Failure to have prepared strategy (plan B and C)

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NAP4 Lessons Learned
Emergency Percutaneous Cricothyrotomy failed 60
of the time
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NAP4 Lessons Learned

• A common theme was failure to plan for failure
• In some cases when airway management was
  unexpectedly difficult the response was
  unstructured. In these cases outcomes were
  generally poor.
• The project identified numerous cases where awake
  fiber-optic intubation was indicated but not used

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NAP4 Lessons Learned

• Aspiration was the single most common cause of
  death in anesthesia events
• Importantly most aspirations occur due to failure
  to recognize risk factors and failure to adjust
  the anesthetic technique accordingly
• Aspiration remains the most frequent cause of
  airway related deaths during anesthesia.

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NAP4 Lessons Learned

• One third of the events occurred during emergence
  or in recovery. Obstruction was the common cause
  in these events
• Recommendations
• Nasal Trumpets
• Oral Airway
• Airway exchange catheter
• SGA prior to removal of ETT (Bailey Maneuver)
• Awaken patient with SGA in place

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Predictors of Difficult Mask Ventilation

• Beard
• OSA
• Obesity
• Male Gender
• Mallampati class III or IV
• Neck Circumference

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Predictors of Difficult Intubation

• Inadequate Preoperative Assessment.
• History of difficult intubation
• Inadequate equipment
• Experience not enough.
• Poor technique.
• Increased Age
• Mallampati III or IV

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Anatomical Factors Affecting Laryngoscopy

• Neck Circumference (Single Major Predictor in
  Obese)
• Short Neck.
• Protruding incisor teeth.
• Long high arched palate.
• Increase in either anterior depth or Posterior
  depth of the mandible decrease in Atlanto
  Occipital distance
• Limited cervical range of motion
• Small mouth opening
• Temporomandibular joint pathology

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Basic Airway Evaluation in All Patients

• Previous anesthetic problems
• General appearance of the neck, face, maxilla and
  mandible
• Jaw movements
• Head extension and movements
• The teeth and oropharynx
• The soft tissues of the neck
• Recent chest and cervical spine x-rays

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Think L-E-M-O-N When Assessing a Difficult Airway

• Look externally.
• Evaluate the 3-3-2 rule.
• Mallampati.
• Obstruction?
• Neck mobility.

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L Look Externally

• Obesity or very small.
• Short Muscular neck
• Large breasts
• Prominent Upper Incisors (Buck Teeth)
• Receding Jaw (Dentures)
• Burns
• Facial Trauma
• Stridor
• Macroglossia (Lg Tongue)

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E-Evaluate the 3-3-2 Rule

• 3 fingers fit in mouth
• 3 fingers fit from mentum to hyoid cartilage
• 2 fingers fit from the floor of the mouth to the
  top of the thyroid cartilage

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E-Evaluate the 3-3-2 Rule
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• M- Mallampati classification

Class-I
Class-II
soft palate, fauces Uvula, pillars.
the soft palate, fauces and uvula
Class-III
Class-IV
soft palate and base of uvula
Only hard palate
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Mallampati ?
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Cormack Lehane Grading
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O-Obstruction

• Blood
• Vomit
• Teeth
• Dentures
• Epiglottis
• Tumors
• Foreign Body (piercings)

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N-Neck mobility -Measurement of
Atlanto-Occipital Angle
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Atlanto-Occipital Angle
Estimates the angle traversed by the occluded
surface of the upper teeth Grade I --- gt
35 Grade II - 22-34 Grade III 12-21 Grade
IV -- lt 12
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Thyromental Distance

• Measure from upper edge of thyroid cartilage to
  chin with the head fully extended.
• A short thyromental distance equates with an
  anterior larynx
• Greater than 7 cm is usually a sign of an easy
  intubation
• Less than 6 cm is an indicator of a difficult
  airway
• Relatively unreliable test unless combined with
  other tests

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Thyromental Distance
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MANAGEMENT PLAN OF ANTICEPATED DIFFICULT AIRWAY

1. Discussion with colleagues in advance
2. Equipment tested before
3. Senior help backup
4. Definite initial plan (A) for ventilation and
   intubation
5. Definite plan (B) than option of awake intubation
6. Ideal situation surgery team standby

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Preoxygenation

• Two Techniques Common in Use
• Tidal volume breathing (TVB) of 100 oxygen via a
  tight-fitting face mask for 5 minutes (Preferred
  Method)
• Deep breaths/Vital Capacity 4 times within 0.5
  min (Time to desaturation is consistently shorter
  then preferred method)
• Why Preoxygenate?
• O2 Consumption Vo2250ml/min and 2500ml O2 in FRC
  (after preO2) 10 minutes to use this O2

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Airway Management A-B-C

• Start with Plan A
• If plan A fails-
• Go to plan B
• If plan B fails-
• Go to plan C

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Plan A (ALTERNATE)

• Different Length of blade
• Different Type of Blade
• Different Position
• Different Equipment

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Plan B (BVM and BLIND INTUBATION Techniques )

• Mask Ventilation
• Bougie
• Combi-Tube?
• LMA an Option?
• Fiberoptic?

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Plan-C Cant Intubate.. Cant Ventilate

• Needle Cricothyrotomy
• Transtracheal Jet Ventilation
• Retrograde Wire Intubation

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Failure.. Why does it happen

• No critical discussion with colleagues about
  proposed management plan
• No request for experienced help
• Exaggerated idea of personal ability
• Ill-conceived plan A and/or plan B
• Poorly executed plan A and/or plan B
• Persisting with plan A too long, starting the
  rescue plan too late
• Not involving, and preparing, surgical colleagues

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GALLERY OF TOOLS
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Rigid Laryngoscope Blades Of Alternate Design And
Size
Mc Coy
Macintosh
Magill
Miller
Polio
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Video Laryngoscopy
Airtraq McGrath C-Mac
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Video Laryngoscopy

• VL Calls on a Alternative Skill Set
• In Critical Situations Unpracticed Techniques may
  not be Helpful

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Video Laryngoscopy

• Use a stylet and shape it to match your VL Blade
• Watch the patient not the monitor when
• inserting the VL Blade
• Trouble passing tube
• -Withdraw
• -Lift Less
• -Drop your angle

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Video Laryngoscopy Versus Direct Laryngoscopy

• Improved Glottic View
• Experienced vs Inexperienced
• Cost
• Standard of the future?
• Picture Confirmation?

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Bullard Rigid FiberopticLaryngoscope

• Time
• Experience
• Limited Maneuverability

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Stylet Devices
Optical Stylet
Lighted Stylet

• No Nasal Intubation
• No Suction
• Limited to above Cords

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• GUM ELASTIC BOUGIE (GEB)
• First used in England
• Cheap
• Good in patients in whom
• only epiglottis is visualized

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Supraglottic Airways SGA
Combitube
LMA
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The Esophageal-Tracheal Combitube

• Useful as emergency airway
• Two lumens allow function whether place in
  esophagus or trachea
• Esophageal balloon minimizes aspiration

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Laryngeal Mask Airway
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VARIATIONS OF LMA

• LMA Classic (standard)
• LMA Flexible (reinforced)
• LMA Unique (disposable LMA)
• LMA Fastrach (intubating LMA)
• LMA C-Trach (Visualization/Intubation)
• LMA Proseal (gastric LMA)

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LMA Fastrach (Intubating LMA)

• Rigid, anatomically curved, airway tube that is
  wide enough to accept an 8.0 mm cuffed ETT and is
  short enough to ensure passage of the ETT cuff
  beyond the vocal cords
• Rigid handle to facilitate one-handed insertion,
  removal
• Epiglottic elevating bar in the mask aperture
  which elevates the epiglottis as the ETT is
  passed through
• Available in three sizes, one size for children,
  two sizes for adults

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LMA C-Trach

• Ventilation
• Visualization
• Intubation

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LMA-Proseal

• High seal pressure - up to 30 cm H20 - Providing
  a tighter seal against the glottic opening with
  no increase in mucosal pressure
• Provides more airway security
• Enables use of PPV in those cases where it may be
  required
• A built-in drain tube designed to channel fluid
  away and permit gastric access for patients with
  GERD

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LMA-Proseal
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Fiberoptic Aided Intubation

• Most Versatile Tool Available for Difficult
  Intubation
• Optical Elements are Small
• Visualization Below the Cords
• Awake Intubation
• Unique Skillset
• Lens Contamination
• Cost

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Cant Ventilate/Cant Intubate
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Cricothyrotomy

• Airway established through the Cricothyroid
  Membrane
• Not a Tracheostomy
• Large Bore Catheter
• Expected skill of the Anesthetist
• Contraindicated in Neonates and Children under
  age 6

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Transtracheal Jet Ventilation

• Maxillofacial, Pharyngeal, or Laryngeal Trauma,
  Pathology or Deformity
• 16-Gauge or Larger (16g- tidal volume 400-700)
• 15-30 psi with Insufflation 1-1.5 sec.
• Specialized systems capable of using Low-pressure
  O2

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Retrograde Intubation

• Local Anesthesia of the airway, skin wheel at
  puncture site.
• Cricothyrotomy performed with air aspiration
• Retrograde wire is advanced until it emerges from
  the mouth. (Magill Forceps)
• Wire is Clamped/Secured at the entry site
• ETT advanced over the wire (Many Techniques)
• Wire removed leaving ETT in place

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Retrograde Intubation
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Extubation of the Difficult Airway
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Airway Exchange Catheter

• Extubation in a controlled manner with a AEC
• Well tolerated
• Airway can be reintubated
• Can deliver Oxygen
• Provides an avenue for suction

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Airway Exchange Catheter

• Localize the airway through existing ETT
• Mark AEC at required depth (tube depth 3 CM)
• Insert AEC and remove ETT
• Tape AEC in place
• Assess for removal of AEC

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Bailey Maneuver

• Exchange of ETT for a LMA
• Decreased Severity of
• Cough
• Maximum change SBP
• Maximum change HR
• Sore throat

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Bailey Maneuver

• Patient is Deep
• Oral-pharyngeal suction
• Deflated LMA placed behind ETT
• LMA cuff inflated
• ETT cuff deflated and removed
• LMA used for ventilation

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What's New in the ASA Difficult Airway Algorithm
2003
2013
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What's New in the ASA Difficult Airway Algorithm
Assess Likelihood and Impact section.
Added Difficult Supraglottic airway
placement Separated Intubation and Laryngoscopy
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What's New in the ASA Difficult Airway Algorithm
2003
2013
Basic Management Choices Video-assisted
Laryngoscopy as initial approach to Intubation
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What's New in the ASA Difficult Airway Algorithm
2003
2013
LMA changed to SGA
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What's New in the ASA Difficult Airway Algorithm
2003
2013
Video-Assisted Laryngoscopy Listed first under
Alternative Difficult Intubation Approach
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What's New in the ASA Difficult Airway Algorithm
2003
2013
Under Invasive Airway Access Percutaneous airway
techniques and jet ventilation remain but are
de-emphasized
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Two For The Road
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Two For The Road

• Be familiar with alternative intubating
  techniques and use them on a regular basis in
  your day to day practice.

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THANK YOU