Airway Management of Patients with a Bloody Airway

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Airway Management of Patients with a Bloody Airway

• Orlando Hung
• Departments of Anesthesia, Surgery
• and Pharmacology,
• Dalhousie University
• Halifax, Nova Scotia

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Objectives

• Case presentation
• Evidence based airway management
• Strategies to secure the airway of patients with
  a bloody airway

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Case Presentation

• A 68 yo patient with uncontrollable epistaxis for
  2 days presents to the OR for an emergency
  exploration. He is hemodynamically stable.
• Apart from smoking, he is otherwise healthy with
  no meds and no allergies.

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Basic Principle in Airway Management
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Principles of Airway Management
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Which of the following is a reasonable technique
to secure the airway?

• Non-visual techniques (blind technique)?
• Direct laryngoscopy using a Macintosh blade?
• Intubation using a flexible bronchoscope?
• Video-laryngoscopes?
• Surgical airway?

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Assuming that you have chosen a specific
intubation technique, how are you going to do it?

1. Awake?
2. Under general anesthesia?
3. Under general anesthesia with RSI?

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What did we do?

• Ensure stable hemodynamics
• Since he could not tolerate lying down flat on
  his back, dinitrogenation was achieved (PreO2) in
  a sitting position
• Double setup with surgical AW as a backup
• RSI using CMAC (direct vision vs video display)
  was successful

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How did we do it?
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Patients with blood in the oropharynx have an
increase risk of

• Hypotension
• Difficult intubation
• Pulmonary aspiration
• Hypoxemia

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What is available in the literature to guide us
managing patients with a bloody airway?
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Post Tonsillectomy Bleed

• Retrospective study
• 475 pediatric patients
• Rapid sequence induction and intubation (84),
  modified RSI (5.5), mask induction (3.2),
  through trach (0.4), unknown (6.1)
• Most common adverse event - Hypoxemia (9.9,
  during emergence and extubation)
• 13 patients (2.7) were difficult to intubate
  (even though initial intubations were easy) but
  all intubations were successful after 2 attempts

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Simulated difficult airway with bleeding

• Prospective, randomized, crossover study
  involving 39 anesthesia practitioners
• Manikin with immobilization of C-spine and bleed
  in the oropharynx
• Mean intubation time
• 47.6 sec for Glidescope
• 21.4 sec for Macintosh
• Adjustment maneuver(s)
• 2.7 for Glidescope
• 1 for Macintosh
• Failure
• 4 for Glidescope (took gt 120 sec)
• 3 for Macintosh (esophageal)

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Simulated difficult airway with bleeding

• The investigators concluded that the Glidescope,
  used by experienced anesthesiologists in a
  simulated difficult airway, had an inferior
  performance compared to the Macintosh
  laryngoscope in terms of intubation time, number
  of intubation attempts, and number of adjustment
  maneuvers.

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Hemorrhagic airway in cadavers

• Freshly prepared cadavers with artificial blood
  in the airway
• 22 emergency medicine and anesthesia residents
• Intubation time
• CMAC 44.6 33.6 sec
• Video blade w suction - 10.1 12.7 sec
• Failures
• CMAC - 6
• Video blade w suction - none

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Hemorrhagic airway in cadavers

• The investigators concluded that the integrated
  video scope with suction improved intubation time
  and success compared to that of the traditional
  CMAC with Yankauer suction

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General principles in securing an airway in
patients with blood in the oropharynx

• Preparation treat hypovolemia, semi-sitting,
  dinitrogenation, suction(s) ready, NG?
• May consider awake intubation, but topicalization
  can be problematic, so most would use RSI
• Avoid blind techniques (lightwand, digital,
  intubating LMA) if at all possible
• Intubation using a laryngoscopy under direct
  vision if at all possible
• Laryngoscopy under indirect vision if there are
  anticipated difficulties (Rigid fiberoptic
  laryngoscopes or video llaryngoscopes)
• Intubation using a flexible fiberoptic
  bronchoscope would be difficult

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General principles in securing an airway in
patients with blood in the oropharynx

• Consider a surgical airway when everything fails,
  and be ready (double set-up)

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Principles of Airway Management
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Selection of a specific airway technique depends
on the clinical situation