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Difficult Airway Management. Airway management is really easy…. Except when it isn’t. DEFFINATION. Difficult Intubation is: Failure to intubate with conventional laryngoscopy after an optimal/best attempt with: Reasonable experienced laryngoscopist No significant resistive muscle tone - PowerPoint PPT Presentation
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Difficult Airway Management
Airway management is really easy….
Except when it isn’t
DEFFINATIONDifficult Intubation is:Failure to intubate with conventional laryngoscopy after
an optimal/best attempt with:• Reasonable experienced laryngoscopist• No significant resistive muscle tone• Use of optimal sniffing position• Use of external laryngeal manipulation• Change of laryngoscope balde type a single time, and• Change of laryngoscope balde length a single time
PREVALENCEFailed tracheal intubation 0.05 – 0.35 %
Failed tracheal intubation with inadequate mask ventilation 0.01 – 0.03 %
This is in OR when:• Plan in advance• Can’t get airway .. awaken patient .. Regroup
• go for coffee
If only they looked this good…
But our options are different
More Difficult Situation:
What makes it difficult in emergency situation
Training/requirements Non-controlled settings Limited pre-procedural evaluation Hypoxia, hypotension, agitation, dynamic
medical conditions Numerous logistical & implementation issues
MOST OF OUR PATIENTS ARE ALREADY “DIFFICULT AIRWAYS” BY “OR” STANDARDS.
The American Society of Anesthesiology (ASA) has noted:
“there is strong agreement among consultants that preparatory efforts enhance success and minimize risk”
And “The literature provides strong evidence that specific strategies facilitate the management of the difficult airway”
Thus identifying a potentially difficult airway is essential to preparation and developing a strategy.
How to identify a difficult airway?
We will not talk about
• The basic anatomy of the Airway
• BLS airway maneuvers and Endotracheal Intubation by Oral and Nasal means
• The concept and procedure of RSI
Airway EvaluationPast Medical History
Decreased cervical mobility
Anatomic upper airway abnormalities
History of Previous Problems in surgery
Predictors of difficult mask ventilation “BONES”:(two or more)
Beard
Obesity with BMI > 26
No teeth
Elderly > 55
Snorers
Airway Evaluation
Dr. Binnions LEMON Law: An easy way to remember multiple tests
• Look externally
• Evaluate 3-3-2 rule
• Mallampati
• Obstructions
• Neck mobility
Airway Evaluation
LEMON Law - Look externally Obesity or very small. Short Muscular neck Large breasts Prominent Upper Incisors (Buck
Teeth) Receding Jaw (Dentures) Burns Facial Trauma S/S of Anaphylaxis Stridor
Airway Evaluation
LEMON Law - Evaluate 3-3-2 rule Mouth opening ≥ 3 fingers Tip of the chin to the hyoid bone ≥ 3 fingers Hyoid bone to the top of the thyroid cartilage ≥ 2
fingers
Airway Evaluation
Airway EvaluationLEMON Law – Mallampati
(difficult direct laryngoscopy Cormack & Lehane grading)
Airway EvaluationLEMON Law - Obstructions
Blood Vomitus Teeth Tumers Epiglotitis
LEMON Law - Neck mobility
Prior condition Surgery Rheumatoid arthritis Osteoarthritis Others
Airway Evaluation
What alternative tools do we have?
Airway Rescue Tools
Airway Rescue Tools
• Bag valve mask• Combitube• LMA• Intubation LMA• Fiberoptic: rigid,
flexible
• Lightwand• Bougie• Transtracheal jet• Retrograde• Cricothyrotomy• Tracheostomy
Nasopharyngeal &Oropharyngeal Airways
COPA – Cuffed Oral-pharynageal Airway
Laryngoscopes
Flexible Tip Laryngoscope
Flexiblade
CL (Corazelli-London) Flexible Tip
Laryngoscope
BURPbackwardsupwardsright pressure
Cricoid pressure vs External Laryngeal Manipulation
Bougie or Eschmann Stylette
Lighted Stylette
Lighted Stylette
Combitube Airway
Combitube Airway
Pharyngeal-Tracheal Lumen Airway (PTL)
Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA)
Laryngeal-Tracheal Airway
Intubating LMA (iLMA)
Intubating LMA (iLMA)
Intubating LMA (iLMA)
Intubating LMA (iLMA)
Intubating LMA (iLMA)
Retrograde Tracheal Intubation
Retrograde Tracheal Intubation
Flexible Fiberoptic Scope
Flexible Fiberoptic Scope
Rigid Fiberoptic Scope
Rigid Fiberoptic Scope
Bullard Wu Scope
Rigid Fiberoptic Scope
Upsher Levitan Scope
Video Laryngoscope
Glidescoe McGrath
Video Laryngoscope
LMA C-Trach
Video Laryngoscope
Surgical Airway: Cricothyroidotomy
Surgical Airway: Cricothyroidotomy
Surgical Airway: Cricothyroidotomy
Quicktrach Emergency Cricothyrotomy
Tran-Tracheal Jet Ventilation (TTJV)
TTJV
Awake Intubation
Expired CO2 Confirmation
YELLOW = CO2 PURPLE = NO CO2
Difficult AirwaySpecific strategies:• Appreciate the importance of developing
a primary and secondary approach• Identify fundemental prenciples, as
adapted from ASA Difficult Airway Algorithm
• Know when to consider an airway “failed” and what takes priority when an airway is failed
Difficult Airway Before intubation
• Do we have to intubate?
• CPAP ?• PPV with BVM or Demand Valve?• Nasal ETT?
Difficult AirwayManagement
• Prearranged Emergency airway trolley available?
• Most senior staff• Emergency airway algorithm• Discussion with colleagues in advance.• Deliver supplemental O2
Difficult AirwayUunexpected Difficult Airway Proble
• Unexpected difficult airway is mostly gone worse because mainly GA is already given including (NMB)
• Equipment may not be in hand.
• Senior and back up plan not available.
Difficult Airwaywhat are we going to do if we don’t
get the tube? Plans “A”, “B” and “C” Know this answer before you tube.
Plan A: Alternate
• Different Length of blade• Different Type of Blade• Different Position• BURP
Plan B: Blind Techniques BVM Bougi Videolaryngoscope LMA, iLMA Combitube Retrograde intubation? TTJV?
Plan C: Can’t intubate, Can’t ventilate
• Cricthyrotomy (needle or surgical)• Tracheostomy
1alternative
2alternative
3alternative
4 alternative
1Manipulation of airway different blade, bugie
2LMA, ILMA, CombitubeBougi, videolaryngoscope
3Trantracheal Jet Ventilation?Retrograde intubation?
4Cricothireotomy, Tracheostomy
Difficult Airway
Airway Rescue
Pearls of Airway Management• Be familiar with all airway rescue tools and
techniques• Recognize the difficult airway• If you can’t intubate – Bag!• If at first you don’t succeed, change
something• Don’t turn difficult airways into failed airways• Plan ahead, and communicate that plan• Get help early, often
Mandibular Aplasia
Thank you!
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