What equipment should be in your Difficult Airway Cart ?

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What equipment should be in your Difficult Airway
Cart ?

• Margaret Healy
• CNM 2 Anaesthesia
• University College Hospital
• Galway

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What is a Difficult Airway?

• The difficult airway is defined as the clinical
  situation in which a conventionally trained
  anaesthetist experiences difficulty with mask
  ventilation, difficulty with tracheal intubation,
  or both

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Difficult Airway Society recommendations

• Practitioners should be competent in a number of
  core airway skills.
• Work in an appropriate environment (trained
  assistance, with access to a range of airway
  devices and techniques, appropriate monitoring
  during surgery and facilities for the appropriate
  level of post op care)
• That equipment is stocked in dedicated trolleys.
  These should be regularly checked and stocked.
  The exact number and location of each trolley
  should be determined locally
• All anaesthetists and anaesthetic assistants
  should be familiar with the contents and location
  of the trolley
• Training should be provided in the use of
  equipment selected by each department
• There should be a Consultant Airway Coordinator
  in each department, a training room and dedicated
  lists for airway training

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CORE SKILLS

• LMA for ventilation
• FOI through LMA, Aintree or other airway
• ILMA
• Indirect laryngoscopes Glidescope, Airtraq etc
• Emergency cricothyrotomy

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Difficult Airway Trolley

• A shelf and 5 Drawers that follow sequence of
  Difficult Airway Algorithm
• Mobile
• Robust
• Clearly labelled
• Easily cleaned
• Attach DAS algorithms
• Restocking list

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Recommended equipment for management of
unanticipated difficult intubation

• DAS guidelines algorithm flowcharts
• Equipment list for restocking
• At least one alternative blade(e.g. straight,
  McCoy)
• Intubating LMA (Size 3,4,5 with dedicated tubes
  and pushers)
• Flexible fibreoptic laryngoscope (with
  portable/battery light source)
• Aintree Intubation Catheter
• Proseal LMA / Supreme LMA
• Cricothyroid cannulae with High pressure jet
  ventilation system (Manujet) OR
• Large bore cricothyroid cannulae (e.g. Cuffed
  Melker) OR
• Surgical Cricothyroidotomy kit

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Miller Blades (Straight)

• The Miller blades are commonly used for infants.
  It is easier to visualize the glottis using these
  blades than the Macintosh blade in infants, due
  to the larger size of the epiglottis relative to
  that of the glottis.

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Levering Laryngoscope (McCoy)

• Hinged tip which facilitates elevation of the
  epiglottis
• Less force required to intubate
• Improves view at laryngoscopy
• Useful in patients wearing cervical hard collars
• Inexpensive
• Steep learning curve

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Supraglottic Devices

• Supraglottic devices are the suitable alternative
  to endotracheal intubation, Useful when
  endotracheal intubation has failed
• Suitable for use by those with limited experience
  with endotracheal intubation
• Should be immediately available for every
  difficult airway situation
• Various types available

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Fastrach (Intubating LMA)

• Advanced version of the standard LMA, which
  allows a specifically designed ETT to be passed
  blindly into the trachea
• Useful in cant intubate, cant ventilate
  scenarios
• Allows fast insertion into correct position
  without moving patients head or neck
• Can be used alone or as a guide to intubation
• Facilitates ventilation between ILMA insertion
  and ETT insertion
• Available in 3 sizes, 3, 4 5 with dedicated
  ETTs available in 6 / 6.5 / 7 / 7.5 8mm

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LMA Pro-Seal

• Not necessarily a Difficult Airway Device, but is
  useful in situation where patient has not been
  fasting
• May be useful in failed obstetric intubation
• This has an extra tube which provides excess
  access to stomach contents
• Protects against aspiration by providing an
  escape for unexpected regurgitation
• Drain tube prevents against gastric insufflation

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LMA Supreme

• Quite new to the market, combines all the best
  features of all previous LMA except you cant
  intubate through it
• The SLMA is easily and rapidly inserted,
  providing a reliable airway and a good airway
  seal
• Rates of failure, manipulations required and
  complications are very low.
• Can be used when tracheal intubation fails in
  non-fasted patients
• Can be used in CPR
• Useful in failed intubation and the cant
  intubate-cant ventilate situation
•  

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Fibreoptic Bronchoscope
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Fiberoptic Intubation (FBI)

• The use of a flexible bronchoscope to intubate
• The endotracheal tube is passed directly over the
  bronchoscope into the trachea
• Uses - Patients with difficult airways
• - Pre-operative assessment
• - Extubation assessment
• Advantages
• This technique allows direct visualization of the
  airway
• Direct confirmation of ETT placement
• Can be done awake
• Disadvantages
• Expensive, difficult, requires care and skill
• View may be hampered by blood or secretions
• Requires detailed decontamination / traceability
  

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Berman Airway

• Berman, an American anaesthetist , designed
  airways to aid blind intubation
• Useful to aid oral fibreoptic intubation
• Also useful as a bite block

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Aintree Intubation Catheter

• Hollow bougie which fits over a standard
  intubating fibrescope
• Aids intubation through a dedicated airway such
  as a laryngeal mask
• Place LMA, load Aintree onto fibrescope, pass
  fibrescope to the carina and slide off the
  aintree. Remove the fibrescope and LMA and
  intubate over the Aintree
• Possible to ventilate via this catheter if
  necessary, throughout the intubation procedure

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Surgical Techniques

• A cricothyrotomy is only indicated when all other
  devices and techniques have failed or are not
  available
• Final step for CICV in all airway algorithms
• Quicker than a tracheotomy
• Life saving
• Convert to definitive airway asap
• Must be provided on all carts

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Surgical Airway Technique

• 3 different techniques
• Needle Cricothyrotomy TTJV
• (Manujet)
• Large Cannulae Cricothyrotomy (Melker /
  Quicktrach)
• Surgical Cricothyrotomy

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1.Needle Cricothyrotomy (Manujet III with Jet
Ventilation Catheter)

• Useful for elective or emergency TTJV
• Perc puncture of cricothyroid ligament
• It consists of an injector with pressure gauge
  and adjustable driving pressure (0-4 BAR)
• Catheters available in 3 sizes Adult 13g, Child
  14g and Baby 16g

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1.Transtracheal Jet Ventilation (TTJV)

• Jet ventilation using either specialized
  ventilator or high pressure driven valve circuit
  via a catheter passed through the cricothyroid
  membrane
• Similar technique to previous
• Disadvantages
• Requires high pressure gas source
• May cause subcutaneous emphysema,
  pneumo-mediastinum, pneumothorax or other types
  of barotrauma
• Uses
• Emergency ventilation in the cant intubate
  cant ventilate scenario

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2. Cricothyrotomy Catheter (Melker cuffed/
Quicktrach)

• Syringe
• 18g Introducer Needles (5cm 7cm)
• Guidewire
• Curved Dilator
• Airway Catheter

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2. Large Cannulae Cricothyrotomy

• Used for emergency airway access when
  conventional ETT intubation cannot be performed
• Percutaneous entry ( Seldinger ) technique via
  cricothyroid membrane
• Dilate the tract and tracheal entrance site to
  permit passage of the emergency airway
• Cuffed catheter to protect and control airway

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3.Surgical Cricothyrotomy

• Requirements
• No 11 blade
• Size 6 Shiley tracheostomy
• ( OR small ETT size 5.0-6.0)
• Small artery forceps

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Technique

• Head fully extended
• longitudinal incision is made through the skin
  and subcutaneous fat over the thyroid and cricoid
  cartilages
• Tissue bluntly dissected
• Cricothyroid ligament is transversely incised
• Tracheal tube inserted

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Accessories

• Fibreoptic Bronchoscopy accessories suction
  adaptor, irrigation valve, camera head, light
  cable, Leak tester,
• mouth guard,
• Berman airway
• Endoscopy masks
• Airway anaesthesia nebuliser, atomiser,
• Xylocaine Spray , Xylocaine 4 topical,
• Co-Phenylcaine
• Battery Light Source

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Documentation

• D.A.S. guidelines
• Set up instructions
• Decontamination Instructions
• Checking / Restocking List

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Conclusion

• Lack of clear instructions
• Technology is changing quickly
• Core skills are vital
• Difficult Airway devices should be used in
  routine cases to ensure familiarity
• ?? Standard Difficult Airway Cart nationally

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