Preparing for the Critical Airway-not just the Difficult Airway-in the PICU

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Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU

• Jeffrey Burns, M.D., M.P.H.
• Chief, Division of Critical Care Medicine
• Childrens Hospital Boston
• Associate Professor of Anesthesia and Pediatrics
• Harvard Medical School

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Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU

• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist

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Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU

• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist

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Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU

• Although technical difficulty is the most feared
  and studied aspect of airway management, it is
  not the only aspect impacting the progression of
  events. The outcome of the critical care airway
  management is the result of many variables not
  included in difficult airway management
  algorithms.
• Matioc, Adrian A. MD Arndt, George MD Jofee,
  Aaron MD
• The critical airway The difficult airway in the
  adult critical care. Critical Care Medicine.
  37(3)1175-1176, March 2009.

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Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU

• Airway management in the intensive care unit is
  not a single provider technical event. The
  critical airway (CA) concept can be used to
  address organizational needs for airway
  management in the intensive care unit. CA
  management starts with the design of the
  patient's bed, the workplace (intensive care unit
  room), and the airway device such that it will
  allow an ergonomic approach to the patient's
  airway in minimal time. It also assumes training
  of the helping staff and continuous effort from
  the airway provider to improve clinical and
  technical skills.
• Matioc, A Arndt, G and Jofee, A The critical
  airway The difficult airway in the adult
  critical care.LetterCritical Care Medicine.
  37(3)1175-1176, March 2009.

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Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU

• The difficult airway has been defined as the
  clinical situation in which a conventionally
  trained anesthetist experiences difficulty with
  mask ventilation of the upper airway, tracheal
  intubation, or both
• Yet all patients in the Pediatric ICU should
  initially be viewed as having a potentially
  critical airway
• Making the critical care environment as conducive
  to difficult airway management as the operating
  room requires planning and teamwork.

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Increased oxygen consumption in the pediatric
patient less reserve time to manage the airway
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Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU

• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist

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Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU

• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist

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Predicting a Difficult Airway

• Clinical Examination
• mouth opening
• back of mouth-Mallampati
• ?lower teeth ride beyond upper teeth
• Movement of the cervical spine
• C2-C8 nodding to and fro
• Delikan warning sign

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Predicting a Difficult Airway
Anatomical Distance Critical
Distance Thyro-mental distance 6.0 cm (Patil
distance) Sterno-mental distance 12.5 cm (Savva
distance) Head fully extended on the neck with
mouth closed
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Causes of a Difficult Airway

• Improper Positioning
• Anatomical Abnormalities
• Musculoskeletal Problems
• Cervical Rigidity
• Temporomandibular Joint Disorders
• Inflammatory Processes
• Neoplasms
• Trauma

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Causes of a Difficult Airway

• Improper Positioning

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Positioning for Tracheal Intubation
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Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU

• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist

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Would you fly with pilots who did not perform the
takeoff checklist?
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Predicting a Difficult Airway

• Clinical History
• Clinical Examination
• Mouth Opening-Mallampati Classification
• Jaw Movement
• Inspection of the Mouth
• Cervical Spine Mobility
• Measurements

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BURP Displace the Thyroid cartilage Backwards,
Upwards, and to the Right
Knill RL. Difficult laryngoscopy made easy with a
BURP. Canadian Journal of Anaesthesiology
19934027982.
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Mind what you have learned. Save your patient it
can!
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Jeffrey.Burns_at_Childrens.Harvard.EDU No conflicts
or financial disclosures to convey