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Professor’s Rounds 2014 Program 2 - PR20142 Approved for 1 contact hour of CRCE® credit per participant who successfully completes the test.
Management of the
Difficult Airway
© 2015 American Association for Respiratory Care
Page 2
OVERVIEW
Management of the Difficult Airway AARC Professor’s Rounds 2014 – Program 2
Description
Various conditions can pose significant challenges in establishing a patent airway. This presentation will discuss these conditions, identify strategies to compensate for the challenges presented, and various adjuncts that are useful in establishing an effective airway in emergent situations.
Objectives
Learn to identify: Discuss basic approaches to endotracheal intubation. Examine advantages and disadvantages of using a laryngeal mask airway. Discuss the strengths and weaknesses of video laryngoscopy. Examine the role of airway adjuncts (stylets) in the management of the difficult airway.
Presenters
Professor William Hurford, MD, FCCM Professor and Chair, Department of Anesthesiology University of Cincinnati Cincinnati, OH
Moderator Douglas Laher, MBA, RRT, FAARC Associate Executive Director American Association for Respiratory Care Irving, TX
CRCE® Credit To earn 1 CRCE credit for participating in today’s program: • View entire presentation • Take the 10-question test (available from Proctor/Site Coordinator) • Answer at least 7 questions correctly • Enter your name and AARC member number on the Attendance and CRCE Log (Please do not enter your Social Security Number) • Receive Certificate of Completion from the Proctor/Site Coordinator
Page 3
PROGRAM SLIDES and NOTES
Slide 1
Slide 2
Objectives 1. Discuss basic approaches to
endotracheal intubation
2. Examine advantages and disadvantages of using a laryngeal mask airway
Objectives 3. Discuss the strengths and
weaknesses of video laryngoscopy.
4. Examine the role of airway adjuncts (stylets) in the management of the difficult airway.
Page 4
Slide 3
Slide 4
Slide 5
Common Problems Limited ability to examine the airway
Limited equipment and positioning
Limited “back-up”
Common Problems Inadequate; difficult pre-oxygenation • Non-invasive ventilation may be
useful
Presence of co-existing; life threatening conditions
Endotracheal Intubation Outside the OR
27 % had > 1 complication; n = 150
76% success rate on 1st attempt; 91% on second
Benedetto WJ et al., J Clin Anes 2007;19:20-24
Page 5
Slide 6
Slide 7
Slide 8
impactednurse.com/pics3/big_airway.jpg
Evaluation Mouth opening
Mallampati score
Evaluation Head and neck
exam
www.ispub.com/.../nasal-fig2.jpg
Evaluation Tracheal
abnormalities
Courtesy Dr. Yash Patil
Page 6
Slide 9
Slide 10
Slide 11
Evaluation Tracheal
abnormalities
Courtesy Dr. Yash Patil
Orotracheal Intubation Preparation
Be calm
• Bring your equipment
• Review the patient's history
• Position the patient
Orotracheal Intubation Preparation
Check for suction
Oxygen, oxygen, oxygen
Airway supplies
Pharmacy-IV access and drugs
Position
Page 7
Slide 12
Slide 13
Slide 14
Positioning for Laryngoscopy Supine:
Pharyngeal and laryngeal axes not aligned
Sniffing: Head elevated neck extended
Positioning Controversies Patient on the floor • Left lateral decubitus
- Adnet F et al. '97,'98
Cervical Spine Injury • Most cervical displacement with mask
- Hauswald et al. '91 (fresh cadavers)
- Suderman et al. '91 Clinical series
Points to Consider Blade Selection Interventions to
improve the view: • Position • Cricoid/thyroid
pressure and tilt • Stylets
Page 8
Slide 15
Slide 16
Slide 17
Anesthesia and Sedation for Endotracheal Intubation
1. Nothing at all
2. Awake intubation with topical anesthetic
3. Procedural sedation
4. General anesthesia with or without neuromuscular blockade
Awake Intubation Oxygenate
Explain calmly; proceed deliberately
Topical anesthetic spray (Lidocaine)
Superior laryngeal or recurrent laryngeal nerve blocks not recommended routinely
Intravenous Sedation Oxygenate
Combine with topical anesthesia
Gradually titrate midazolam / fentanyl
Use propofol, etomidate, dexmedetomidine if skilled and airway adequate
Page 9
Slide 18
Slide 19
Slide 20
Anesthesia and Neuromuscular Blockade
Paralysis converts a spontaneously breathing patient into an apneic patient
Severe hypoxemia will occur before the succinylcholine is gone
Ability to gain surgical access to the airway must be present
Neuromuscular Blockers
Higher success rates during RSI
Lower rate of complications
Not just for the OR anymore?
RSI vs. Etomidate-Only Intubation in Air Medical Setting
Prospective crossover trial (n=49 pts ) of etomidate vs. succinylcholine
Acceptable conditions in 79% of RSI pts and 13% without paralysis
92% of RSI pts vs 25% of pts were successfully intubated
Boseman WP et al. Prehosp Emerg Care 2006; 10:8-13
Page 10
Slide 21
Slide 22
Slide 23
Succinylcholine Succinylcholine provides
better intubating conditions than rocuronium under emergent conditions
Rocuronium vs. Succinylcholine for RSI
Sux superior to roc for intubating conditions
Succinylcholine should still be used as a first line
Rocuronium can be used but should only be used as a second line treatment
Perry JJ et al. Cochrane Database Syst Rev 2008; 16(2):CD002788
Nasotracheal Intubation Alternative to Tracheostomy
Intraoral pathology; intraoral maxillary fixation
Poor mouth opening
Difficult or impossible visualization with direct and/or fiberoptic laryngoscopy
Page 11
Slide 24
Slide 25
Slide 26
Nasotracheal Intubation Longer time to intubate
• Airway uncontrolled
• Increased hypoxia possible
Nosebleeds can be disastrous • coagulopathies
• anticoagulants
• thrombolytics
Verification of Intubation: End-tidal Carbon Dioxide
A fool's gold standard? Not present if:
• pulmonary circulation absent - dead, poor CPR, massive PE
Present with esophageal intubation: • insufflated air, carbonated beverages • 0.2 - 2% CO2 in 33 - 45% of esophageal
intubations (Linko '83;Sum-Ping '89)
Supraglottic Airways
www.i-gel.com
www.indemed.com
www.kingsystems.com
Page 12
Slide 27
Slide 28
Slide 29
LMA and the Difficult Airway Primary airway adjunct when mask ventilation is
difficult or impossible (case reports) Provide routine airway management with
anticipated difficult intubation • LMA placement successful in 29 of 30 pts with
known abnormal airways - Langenstein H. Anaesthetist 44:712, 1995
Aid to endotracheal intubation
Difficult Airways Managed with the LMA
Ankylosing spondylitis
Facial burns
Failed obstetric intubation
Limited mouth opening
Hemifacial microsomia
Percutaneous tracheostomy
Rhematoid arthritis
Obesity
Neck contractures
Motor vehicle accident
Multiple difficult intubations
Unstable neck
Cervical halo
Sitting and prone position
Comparison of Placement of LMA with ETT by Paramedics and Respiratory Therapists
Mean time to successful ventilation: • ETT 206 sec • LMA 39 sec (P < 0.001)
Failed placement (> 3 attempts) • ETT 10/19 (53%) • LMA 0 (P < 0.01)
Reinhart DJ and Simmons G. Ann Emerg Med 24:260, 1994
Page 13
Slide 30
Slide 31
Slide 32
LMA as an Aid to Intubation Blind Insertion
• 6.0 ETT max (#3 & 4); 7.0 (#5) • Length of ETT and removal of
LMA are issues
LMA as an Aid to Intubation Intubating LMA (Fastrach):
success rate 70 - 98%
LMA as an Aid to Intubation Fiberoptic Placement
• Higher rate of success • Passage of fiberscope and ETT may be
difficult
Page 14
Slide 33
Slide 34
Slide 35
The LMA and the ASA Algorithm
Combat Trauma Airway Management: Endotracheal Intubation vs. LMA vs. Combitube Use by Navy SEAL and
Reconnaissance Combat Corpsmen
12 Special Operations corpsmen evaluated in use of each device (randomized) during “live fire” combat conditions
Criterion was establishment of reliable airway within 40 sec
No failures occurred
Calkins MD & Robinson TD, J Trauma 46:927, 1999
Combat Trauma Airway Management: Endotracheal Intubation vs. LMA vs. Combitube Use by Navy SEAL and
Reconnaissance Combat Corpsmen
Mean time to insertion:
• ETT 36.5 sec
• Combi 40 sec
• LMA 22.3 sec (P < 0.05)
ETT considered preferable
Calkins MD & Robinson TD, J Trauma 46:927, 1999
Page 15
Slide 36
Slide 37
Slide 38
Video Laryngoscopy
Kaplan MB, jepm.org
Many Products – More on the Way
Glidescope
McGrath
Stortz DCI
Bonfils
Wu
Bullard
Res-Q-Scope
Coopdech C-scope VLP-100
Stortz C-Mac
Pentax AWS
RIFL
AirTraq
Dozens more…
Types Stylets
Guide channels
Modified laryngoscope blade
Page 16
Slide 39
Slide 40
Slide 41
Bonfils Stylet Retromolar oral insertion
technique – useful when mouth opening is limited
Fixed 40° distal angle
Camera adaptor
Continuous oxygen via tube adapter
https://www.karlstorz.com/
Guide Channel Laryngoscopes
Bullard
Wu
Res-Q-Scope
AirTraq
Pentax AWS
Pentax AWS Fits standard ET
tubes size 6.5 mm and larger
Powered by two lithium CR-123 batteries
135° tip www.ambuusa.com
Page 17
Slide 42
Slide 43
Slide 44
Pentax AWS Fits standard ET
tubes size 6.5 mm and larger
Powered by two lithium CR-123 batteries
135° tip www.ambuusa.com
Macintosh Modifications Coopdech VLP-100
McGrath
Storz DCI
Storz C-Mac
GlideScope
Many others
GlideScope
Page 18
Slide 45
Slide 46
Slide 47
C-Mac Video Laryngoscope
https://www.karlstorz.com/
McGrath
Comparison of Direct and Video-assisted Views of the Larynx During Predicted Difficult Intubation
112 patients with predicted difficult intubation received direct laryngoscopy followed by GlideScope
% of Grade I and II views increased from 63 to 90%
Intubation successful in 98% of cases
Stroumpoulis K et al. Eur J Anaesthesiol 2009; 26:218-22
Page 19
Slide 48
Slide 49
Slide 50
DL vs. GlideScope in Untrained Personnel
20 volunteers attempted 5 intubations with either technique in pts scheduled for surgery
DL used in 217 (78%); GlideScope in 63 (22%) – not randomized
Overall success rate • GlideScope: 93% • Direct: 51% (P < 0.01)
Time to intubation • GlideScope: 63 + 30 sec • Direct: 89 + 35 sec (P < 0.01)
Nouruzi-Sedeh P et al. Anesthesiology 2009:110:32-7
Summary Supraglottic airways, such as the
LMA, are easy and safe alternatives
Video laryngoscopy is the best first alternative to direct laryngoscopy
Summary Sedation makes intubation easier;
neuromuscular blockade even better (if mask ventilation is possible)
Succinylcholine is preferred, but rocuronium is acceptable, for neuromuscular blockade
Page 20
Slide 51
Slide 52
Other CRCE® Credit Opportunities with AARC
The AARC offers a variety of other programs for CRCE Credit. Visit these sites for details.
More Professor’s Rounds topics www.aarc.org/education/professors_rounds/
Meetings www.aarc.org/education/meetings/
Webcasts www.aarc.org/education/webcast_central/
Online courses www.aarc.org/education/aarc_crce/
Benefit for AARC Members!
Webcasts and many of the online courses are free for AARC Members.
Four Axioms for Endotracheal Intubation
1. Expect the intubation to be difficult until proven otherwise
2. A patient may not tolerate even short periods of apnea or hypoxia
Four Axioms for Endotracheal Intubation
3. A patient in extremis requires much less (if any) anesthesia
4. A patient who breathes is better than one that does not
Page 21
TEST
Management of the Difficult Airway AARC Professor’s Rounds 2014 – Program 2
Mark the Corresponding Box for your Response to each Question
7 Correct Out of 10 is Passing Name: __________________ _____________________ AARC Mbr #: _______________ (first) (last) Email Address:___________________________________ Date: _____________________ (required for nonmembers) 1. Approximately 1/3 of emergent endotracheal intubations outside the operating room are
complicated or difficult. True False
2. Ventilation with a laryngeal mask airway is often more difficult than using a traditional face mask
for inexperienced personnel. True False
3. Endotracheal intubation may be accomplished through an LMA. True False 4. LMAs may be used to manage some airways that cannot be intubated with a traditional
endotracheal tube. True False
5. The LMA is an integral part of the American Society of Anesthesiologists difficult airway algorithm.
True False 6. Video laryngoscopes offer a similar field of view to traditional direct laryngoscopy.
True False 7. Stylet laryngoscopes may be useful when a patient’s mouth opening is limited.
True False 8. Guide channel video laryngoscopes may be effective when direct laryngoscopy is difficult.
True False 9. Video laryngoscopes are not very portable and their use is limited to the operating room.
True False 10. The success rates of endotracheal intubation with the Glidescope is similar to direct laryngoscopy
when intubation is predicted to be difficult. True False
Page 22
PARTICIPANT EVALUATION
Management of the Difficult Airway AARC Professor’s Rounds 2014 – Program 2
Please help evaluate this program by taking a moment to answer the following questions. Thank you.
1. My current position is:
_____Staff Therapist _____RT Supervisor/Mgr _____Student _____RT Program Faculty
_____Other (please specify) ________________________________________________ 2. The content of today’s program was relevant and applicable to my job.
_____Strongly Disagree _____Disagree _____Neutral _____Agree _____Strongly Agree 3. Presenters were easily understood and presented the topic well.
_____Strongly Disagree _____Disagree _____Neutral _____Agree _____Strongly Agree 4. Slides on the video were effective in supporting the information presented.
_____Strongly Disagree _____Disagree _____Neutral _____Agree _____Strongly Agree 5. I achieved the learning objectives of today’s program.
_____Strongly Disagree _____Disagree _____Neutral _____Agree _____Strongly Agree 6. Provide any comments you have about this program:
7. List any topics that you would like to see presented as future programs.
Participants: Please return this completed form to your Proctor/Site Coordinator.