Transcript Airway Crises Tools By Hwan Joo MD*

Airway Management
Alex Ho MD
Outline
 Airway Assessment
 Difficult Airway Management
 Closed Claims
 Airway Mx Strategies and Techniques
 Pitfalls
A/W Management
 patency
 protection
 preserve / provide ventilation
 intubation
 extubation
Indications for Tracheal
Intubation
 Patency
 Oxygenation and delivery of PEEP
 Ventilation
 Airway protection from Aspiration
 Tracheal toilet and lung washings
 Route for drug administration
Permutations
 elective vs. emergent
 easy vs. awkward vs. difficult
 location (floor vs. ER/ICU vs. OR)
 awake vs. asleep
 spontaneous ventilation vs. not
 route: nasal, oral, surgical
 personnel: RT, 2nd Anesthesia, Surgeon
 equipment: usual vs. difficult cart vs. Sx
instruments
 special: c-spine, airway injury, raised ICP, etc
Airway Assessment
 ? difficult ventilation +/- intubation
(layngoscopy)
 hx (congential, aquired) and P/E and labs /
special / imaging
 P/E: appearance, BMI
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dentition
MP score
mouth opening, TM distance, jaw subluxation,
C-spine (Alanto-Occiptal Extension)
Airway Assessment
 labs / special / imaging
 PFT's (flow-volume loops)
 endoscopy
 CXR, CT scan (head, neck, chest)
Airway Assessment
 The Mallampati view
may be indicative of
difficult airway
 Negative predictive
value >99% for MP 1-2
 PPV for MP 4 only 40%
 MP and laryngeal view
not very correlative
Case 1
 28 F elective bilateral breast reduction
 Healthy
 “normal” a/w exam
 How to proceed?
Case 1
 Monitors
 Preoxygenate
 IV induction with non-depolarizing muscle
relaxant
 BMV until vocal cords relaxed
 Direct laryngoscopy
 Maybe stubby handle for laryngoscope
Direct Laryngoscopy
 3# Mcintosh blade most
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commonly used
No change in design for
60 years
High success rates in
normal airways (99%)
Simple, universally
available
However, difficult to learn
>50 uses to be proficient
Not so good with difficult
airways
Predictors of Difficult Intubation
(Laryngoscopy) - LEMON
 L=Look externally (facial trauma, large
incisors, beard or moustache, and large
tongue)
 E=Evaluate the 3-3-2 rule
 incisor distance <3 fingerbreadths (6 cm)
 hyoid/mental distance <3 fingerbreadths (6cm)
 thyroid-to-mouth distance <2 fingerbreadths)
Predictors of Difficult Intubation
(Laryngoscopy) - LEMON
 M=Mallampati (Mallampati score 3)
 O=Obstruction (presence of any condition
that could cause an obstructed airway)
 N=Neck mobility (limited neck mobility).
Predictors of Difficult BMV
 male
 obstructive sleep apnea
 MP III or IV
 beard
 * neck radiation
 predicts difficult intubation about 25%
MOANS
 M = difficult mask seal (full beard)
 O = obese or airway obstruction
 A = advanced age
 N = no teeth
 S = snore or stiff lungs
 Hung and Murphy CJA 2004 51:10
Difficult Airway Assessment
 History + P/E
 Trauma
 C-spine precaution
 Blood in airway
 Airway trauma (distal a/w injury)
 Morbid obesity
 Aspiration risk
 Uncooperative patient
 IV access
Airway Mx Evaluation
 Can I oxygenate this patient with a BMV?
 Can I ventilate with a supra-glottic device
(SGD) i.e. LMA?
 Can I place a tube in the trachea?
 Can I secure a surgical airway?
 difficult: when normal Mx will be inadequate
/ contraindicated
ASA Difficult Airway Algorithm
 Recognized difficult airway
 intubation vs non-intubation
 facemask, LMA
 local / regional anesthesia
 Unrecognized difficult airway
 can ventilate
 convert to spontaneous ventilation?
 awake vs asleep
 cannot ventilate
 emergency measures required
Can't Intubate / Can't Ventilate
 emergency!
 call for help
 Non-Invasive
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(LMA)
Combi-Tube
TransTracheal Jet Ventilation
suspension laryngoscopy / rigid bronchoscopy
Can't Intubate / Can't Ventilate
 Invasive
 percutaneous / surgical cricothyrotomy /
tracheostomy
 sternal split
 cardio – pulmonary bypass
 Post Mx care: difficult extubation; update
chart, medical history, notify patient (?
Medic Alert bracelet)
Failed Airway MX
 delayed Sx
 cancelled Sx
 dental damage
 unanticipated ICU admission
 unanticipated surgical airway
 anoxic brain injury
 death
Closed Claims -Caplan, Anesthesiology 1990
 Airway -Largest and most costly form of
injury (34% of all claims, $200,000+ US)
 Inadequate ventilation (34%)
 Esophageal intubation (18%)
 Difficult intubation (17%)
 36% of claims against difficult intubation
cases considered preventable
Closed Claims in Canada
 Between 1993-2003, 50% of all large CMPA
suits in anesthesia were airway related
 Average settlement was $500,000
 75% of patients suffered brain damage or deaths
 50% were associated with difficult airways
 In half of these patients, difficult airway adjuncts were not
used
 expert opinion: pre-op assessment and management
plan, use monitors, follow guidelines
Induction of for Intubation
 OXYGEN +
 Nothing
 Patient already non-responsive
 Medications contraindicated
 Topical lidocaine
 Midazolam, fentanyl
 Etomidate / Ketamine / Propofol ± Sux /
Non-depolarizing paralytic (eg.
Rocuronium)
 Inhalational induction
Difficult Intubation -Mask Ventilation
Possible (Unanticipated)
 re-position pt, stylette, alternate blades,
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smaller ETT, gum elastic bougie
Lighted stylette
Video laryngoscope
Asleep fiberoptic intubation with video Lscope
LMA without intubation
Intubation via LMA or ILMA or Aintree
CombitubeTM
Awaken patient
Basic Moves for SV
 suction
 chin lift (not if Cspine injury)
 jaw thrust
 oral airway
 nasal airway
Basic Moves for BMV
 1/ 2 / 3 person
mask airway
 mask seal (mask
size)
 source of PPV
 not mouth
 self-inflating
 flow-inflating
Positioning / Repositioning
Lighted Stylette (TrachliteTM)
 With experience
 Success rates reported
to be up to 99% in
patients with difficult
airway (Hung, CJA 1995)
 Success rates for
novices 50% (Wilk, Resuc
1997)
 Success rates
decreased in patient
with bull necks and
obese patients
Video Laryngoscopes
Glidescope
 Rigid laryngoscope with
CCD
 View is very clear with no
fogging
 Blade angle 50-60 deg
 Easy to use
 Very rapid learning curve
 Can also be learned by ER
physicians, Surgeons
Glidescope Success Rates with
Experience Joo et al
100
90
80
70
60
50
40
30
20
10
0
Success Rate
0 to 9
10 to 19
20 to 29
30 to 39
> 40
Glidescope with Disposable Blade
Glidescope in Use
McGrath Videolaryngoscope
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Similar to Glidescope
Disposable blade cover
Beautiful all in one design
Optics not be as good
 Narrow field of vision
 More difficult?
 More portable
 More likely to disappear
Video Laryngoscopes
RES-Q-SCOPE
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LCD Screen
Disposable blade
Much cheaper initial cost
However, $50 per use
Case 2
 60 M elective anterior C-spine
decompression and fusion
 Symptomatic neck but not unstable
 Morbidly obese; MP III
 (Significant GERD)
 Looks “awkward”
Case 2
 Variable Mx
 Troop pillow
 Adjuncts (FOB) and help in room
 ? Awake approach
Flexible Fiberoptic Intubation
 Awake fiberoptic intubation
is the gold (Rose CJA 1994)
 Asleep FOI, successful but,
 It may be more difficult due
to
 Airway obstruction or apnea
 Blood in pharynx
 Limited time before oxygen
desaturation
 Should be done with help!
(Tongue traction, jaw thrust)
 ? Patil-Syracuse mask
Laryngeal Mask Airway
 Comes in sizes 3, 4, 5
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(small, medium, large)
Great for ventilation
Insertion easier if you have
deep anesthesia
Does not protect against
aspiration
Not able to deliver high
pressure ventilation
Useful for difficult airways
and failed laryngoscopy
Laryngeal Mask
Airway for intubation
 Success for intubation with conventional
LMA is variable (19-93%)
 Success may be improved by the use of a
pediatric bronchoscope via the ETT in
LMA
 LMA removal may be difficult after
intubation
 Consider LMA without intubation
(Mask) Ventilation Difficult or
Impossible
 Failed intubation is disturbing but…..
 Failed ventilation is universally fatal!
 Choices: Non-Invasive vs. Invasive
 * LMA (iLMA variant; Aintree catheter)
 Combitube
 suspension laryngoscopy / rigid bronchoscopy
 * Transtracheal airway
 transtracheal jet ventilation
 * cricothryotomy
 tracheostomy
Laryngeal Mask Airway
 Success rates for ventilation as high as
 95% after 1 attempt and 98% after 2 attempts
 No decrease in success rates in patient’s
with difficult airways
 Overwhelming data of uses in difficult
airways and in failed ventilation
 may have saved 100’s of lives!
 For IPPV use large LMA’s
Intubating Laryngeal Mask
Airway (ILMA)
ILMA with FOB
 Things of interest
 Elbow connector
 Continuous ventilation
 PVC Tube
 Metal rings in silicone tube
not compatible with FOB
 Better than C-Trach?
 Better manipulation
 Higher Success rates
What is this?
 The view via ILMA is
different from regular
FOB
 The epiglottis is often
distorted
 Obviously blind
intubation failed
 Larger ILMA required
ILMA with FOB
LMA C Trach
 ILMA with LCD screen
 Improved success rates for intubation over ILMA
 Success on normal airways about 90-95%
based on limited studies
 However, need greater mouth opening compared to
ILMA, 2.5cm versus 2.0 cm
 Same success rate for ventilation
 Less trauma
LMA + Aintree Catheter
 Best used with
pediatric
bronchoscope
 Can be placed
through any LMA
 Has fittings for
ventilation
 Allows for exchange
of LMA for ETT
CombitubeTM
 Success rates by nonanesthesiologist with
combitube has ranged (3393%)
 Average beginner success
rates expected to be in the
80-90% range (Anesthesiatrained)
 May be associated with
esophageal injuries and
mediastinitis (Vezina, CJA 1998)
What is the Best Device for Failed
Ventilation? LMA vs. CombitubeTM
 Success is dependent on more on the
operator’s experience than to tool
 Majority of anesthesiologist have little or
no experience with the Combitube
 LMA should be the first choice for difficult
ventilation scenarios
 However, Combitube theoretically
prevents aspiration
Trans Trachea Airway
FOR UPPER AIRWAY OBSTRUCTION
 TTJV (jet ventilation)
 difficult with multiple
complications
 Needle cricothryotomy
 High success rates using
Seldinger technique
 No need for jet ventilation
 Slash or surgical
tracheotomy
 Messy but may do the job
Confirming ETT Placement
 Physical Exam:
 Mist, compliance, chest rise (not stomach),
breath sounds, EDD
 Gold Standard
 laryngoscopy
 ETCO2
 bronchoscopy (vs. endobronchial)
 Improving / stable vitals
 NOT CXR, etc.
Confirming ETT Placement
Failed Intubation
What to do as a Surgeon
 Awaken patient if possible/feasible
 Maintain ventilation and oxygenation
 Facemask
 LMA
 Combitube
 Call Anesthesia
 Surgical Airway
 Attempt ventilation throughout
Airway Tools not for Surgeons
 FOB
 Too much effort required to learn
 Not good with secretions or blood
 Not as useful in unplanned cases (ER)
 Lighted Stylettes
 Again, high learning curve
 Not as useful in patients who are not paralyzed
 High incidence of esophageal intubations
What is the Best Tool for
Surgeons?
 LCD Laryngoscopes are the way of the
future
 Currently, Glidescope is the easiest to use
with the most literature supporting it
 Must Practice on routine patients
 Use it get familiarity
 Bug the anesthesiologists to use it in the OR
 Glidescope + FOB
Glidescope FOB Insertion
Glidescope FOB Intubation
Key Messages
 ABC's, Oxygen, Monitors, Call for Help
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(Declare a crisis)
Secure and preserve ventilation
Avoid multiple similar attempts (ie.
laryngoscopy)
Confirm placement of ETT
Extubation: If in doubt, do not take it out!
Extubation: caution with “Seldinger”
techniques
Final Recommendation
 When faced with a
difficult airway, stay
on the beaten path of
 Practice, Practice…
 Use familiar but
advanced devices
 Do not persist with
techniques that have
failed
 Secure ventilation
Practice in Simulation