Embed Size (px)
Citation preview
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 1/32
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 2/32
INTRODUCTION
• Field intubation success rates:
Oral 80-95%Nasal 60-85%
• RSI not universally available
•
Recognition of difficult airway is important• At least one backup, “rescue” airway
technique is essential
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 3/32
DEFINITION
• Difficult airway: ANYTHING that interferes
with ventilation or intubationAnatomic
Traumatic
Infectious
Allergic
Behavioral
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 4/32
CLUES TO LOOK FOR:
• Prominent incisors
•
Limited jaw / mouthopening
• Short neck
• Big tongue
•
Small mandible• Limited cervical
mobility
• Facial trauma
• Burns
• Neck injury
•
Obesity• Foreign bodies
• Children
• Infections
•
Allergic edema• Neoplasm / irradiation
• Inhalation injuries
• Facial hair
CL
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 5/32
FOUR D’s
• Distortion
• Disproportion
• Dysmobility
• Dentition
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 6/32
MNEUMONIC “BONES”
• Beard
• Obese
• No teeth
• Elderly
• Snoring (sleep apnea)
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 7/32
MALLAMPATI CLASSIFICATION
Class I Class II Class III Class IV
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 8/32
ANATOMY
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 9/32
60-SECOND EXAM “LEMON”
• Look for external difficulty
• Evaluate using 3=3=2 rule
• Mallampati rule (class I & II)
• Obstruction
• Neck mobility
3 fingers fit in mouth
3 fingers fit from mentum
to hyoid cartilage 2 fingers fit from mandible
to top of thyroid cartilage
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 10/32
10-SECOND QUICK EXAM
• Can you see the uvula?
• Can you fit 3 fingers from mentumto hyoid?
• Can the patient extend head back
on neck?
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 11/32
PREPARATION
• Prepare equipment ahead of time
• Check and recheck
• Gather all airway devicesin one bag or area
• Pre-oxygenate with 100% O2
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 12/32
SNIFFING POSITION
• Flex neck on chest 35°
• Extend head on neck 80°
• Use pillow or otherobject under occiput
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 13/32
BURP, OELM, ELM
• Backward
• Upward
• Rightward
• Pressureon thyroidcartilage
• Optimal
• External
• Laryngeal
• Manipulation
• External
• Laryngeal
• Manipulation
Intubator usesBURP to establish
position; assistantholds in place
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 14/32
Helpful device for intubationthat is practical
•
GUM ELASTIC BOUGIE (GEB)Used in England
Cheap
Good in patients in whomonly epiglottis is visualized
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 15/32
Rotate ET tubeuntil bevel faces
posteriorly
GEB in trachea
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 16/32
Helpful devices for intubationthat are NOT practical in the field
• Light wands
• Fiberoptics
• Tracheostomy lights
• Blind techniques
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 17/32
Adjuncts to NasotrachealIntubation
•
Endotrol• Afrin and lidocaine on nasal trumpet
• BAAM whistle
• Positioningstraight back, not upward
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 18/32
Endotrol
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 19/32
BAAM Whistle
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 20/32
RESCUE AIRWAYS
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 21/32
Laryngeal Mask Airway (LMA )and Intubating LMA (ILMA)
•
Used in surgery• Risk of aspiration
• Rescue technique
•Tube must be usedwith curve reversed
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 22/32
LMA and ILMA (cont.)
• Intubating LMAAccepts larger tube
(8.0)
Can be used for rescue
Is expensive• LMA & ILMA not
used in California EMS
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 23/32
COMBITUBE
• Most commonly used
rescue airway in EMS
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 24/32
Needle or SurgicalCricothyrotomy
•
Needle must be usedwith high poweredO2 in adults
• Surgical techniquesforbidden inCalifornia EMS
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 25/32
Preferred SurgicalCricothyrotomy
•
Seldinger techniqueCatheter-over-needle
Wire-through-needle
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 26/32
Confirmation of IntubationTechniques
• AuscultationBoth lung fields and epigastrum
• Persistent oxygenation on pulse oximetry
• Chest wall motion
•
Tube “fogging” • Chest x-ray
• End-tidal CO2
• Esophageal detector device (EDD)
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 27/32
Confirmation of IntubationTechniques (cont.)
•
ALL techniques may be unreliable!• End-tidal CO2 and EDD are MOST
reliable.
•
Both are mandatory in AlamedaCounty policy #10102
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 28/32
End-tidal CO2
• Colorimetric
• Capnography
• Capnometry
• Drawback:
Cardiac arrest state
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 29/32
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 30/32
Esophageal Detector Device
• Drawbacks:
Air in stomach causes false positives
Poorer performance in obese patients
Cold can impact bulb type
MUST be used correctly
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 31/32
SUMMARY
• Be prepared – mentally & logistically
• Know how to assess a potentialdifficult airway
• Use proper techniques
• Utilize assistive devices to facilitateintubation
8/3/2019 20 the Case of the Difficult Airway
http://slidepdf.com/reader/full/20-the-case-of-the-difficult-airway 32/32
SUMMARY (cont.)
• Know when to use rescue techniques
• Confirm your intubation usingmultiple techniques
End-tidal CO2 and EDD are mandatory!
• Monitor patient using pulse oximetryand end-tidal CO2
