Transcript Difficult Airway management & Protocols

Dr.Gayathri Ramanathan
Associate Professor
SRM MEDICAL COLLEGE HOSPITAL &
RESEARCHCENTRE
7/16/2015
1
OBJECTIVES
• Causes of difficult intubation
• Basic airway evaluation
• Management plan for Anticipated difficult airway – Plan A, Plan
B , Plan C & Plan D
• Gallery of tools
• The Expected & Unexpected Difficult Airway
7/16/2015
2
DEFINITION
American society of Anesthesiologist (ASA) suggested
(difficult to ventilate)
 That when sign of inadequate ventilation could not be
reversed by mask ventilation
or
oxygen saturation could not be maintained above 90%
DEFINITION
(difficult to intubate)
 If a trained Anaesthetist using conventional
laryngoscope takes more than 3 attempts
or
more than 10 minute to complete tracheal intubation
15- 50%
ARE ONLY PICKED UP
15%
DIFFICULT INTUBATION
EXTREMELY
DIFFICULT
ABANDON
GS – 1 in 2000
OBG- 1 in 300
CAUSES OF
DIFFICULT INTUBATION
Pre-op assessment
Equipments
Anesthetist
Experience not
enough
Poor technique
Malfunctioning
equipment
Inexperienced assistance
CAUSES OF
DIFFICULT INTUBATION
Patient
1.
2.
Congenital causes
Acquired causes
Basic airway evaluation in all
patients
 Dr. Binnion’s LEMON Law
 BONES
 The 4 D’s
Dr. Binnions Lemon Law: An easy
way to remember multiple tests…
 L ook externally.
 E valuate the 3-3-2 rule.
 M allampati.
 O bstruction?
 N eck mobility.
L: Look Externally
Obesity
Short
muscular neck
Buck teeth
Receding
jaw
Dentures
L: Look Externally
Macroglossia
Stridor
Facial trauma
E:Evaluate the 3-3-2 rule
 3 fingers fit in mouth- Inter incisor distance
 3 fingers fit from mentum
to hyoid cartilage
 2 fingers fit from the floor
of the mouth to the top of
the thyroid cartilage
14
M: Mallampati classification
Class-I
Class-III
soft palate, fauces;
uvula, anterior and
the posterior pillars.
soft palate and base of uvula
the soft palate, fauces Class-II
and uvula
Only hard palate Class-IV
O: Obstruction?

Blood
 Vomitus

Teeth

Epiglottis

Dentures
Tumors

Impacted Objects
N:Neck mobility -Measurement of
Atlanto-Occipital Angle
Thyro- Mental Distance
Measure from upper edge of thyroid cartilage to chin with the head
fully extended.
•
A short thyromental distance = an anterior larynx .
• > 7 cm is usually = easy intubation
• < 6 cm = difficult airway
18
MANAGEMENT PLAN
OF
ANTICIPATED
DIFFICULT AIRWAY
7/16/2015
19
Is mask ventilation going to be
difficult?
Can’t ventilate
Defined by “BONES”
• Beard
• Obesity
• No teeth
• Elderly
• Snoring
Is laryngeal visualization going to
be difficult?
Can’t intubate
Defined by 4 D’s
Disproportion
2. Distortion
3. Dysmobility
4. Dentition
1.
Disproportion
Achondroplasia
Pierre robin
sequence
Acromegaly
Prognathism
Distortion
Burns contracture
Neurofibromatosis
Cystic hygroma
Dysmobility
TM joint Ankylosis
Klippel Fiel
Dentition
Edentulous
Buck teeth
Is cricothyroidotomy going to be
difficult?
Can’t Rescue
 Should assessment reveal a potentially difficult airway
the cricothyroid membrane should be identified and
marked, BEFORE an intervention is undertaken
Possible Options!
Following airway assessment, the person performing the
intubation should be in a position to decide between
three possible options
1. Awake intubation
2. Quick look
3. Induction and paralysis
1. Awake Intubation
The patient needs to be intubated awake
There is significant risk of complications if sedatives
and/or muscle relaxants are administered prior to
airway control.
2. Quick Look
The patient may be sedated for an attempt at direct
laryngoscopy WITHOUT muscle relaxation
(“Quick Look”)
There is some risk of failed laryngoscopy
but
There should be a low risk of failed mask ventilation.
3. Induction & Paralysis
The patient may be induced and paralyzed,
In this case the patient is assessed as having a low risk
of laryngoscopy and/or mask ventilation
Pre-oxygenation: How Much Is
Enough?
Two techniques common in use:
1. Tidal volume breathing (TVB) of oxygen for 3–5
min
2. Deep breaths (DB) 4 times within 0.5 min
Both are equally effective in increasing arterial
oxygen tension (Pao2).
Anesth Analg 1981; 60: 313–5
Pre-oxygenation
Each subject received 5 mg/kg thiopental and 1 mg/kg succinylcholine.
Anesthesiology 2001, 95: 754-759
What are we going to do if we
don’t get the Tube?
 Plans “A”, “B” ,“C” and plan “D”.
 Know this answer before you tube.
Failure -Why does it happens?
 No critical discussion with colleagues about proposed
management plan
 No request for experienced help
 Exaggerated idea of personal ability
 Ill-conceived plan A and/or plan B
 Poorly executed plan A and/or plan B
 Persisting with plan A too long, starting the rescue
plan too late
 Not involving, and preparing, surgical colleagues
GALLERY OF TOOLS
 ILMA
 Video laryngoscopes
 Malleable video stillet- Levitan scope
 Fibreoptic bronchoscope
ANTICIPATED DIFFICULT AIRWAY
ELECTIVE
EMERGENCY
ANTICIPATED DIFFICULT AIRWAY
ANTICIPATED
DIFFICULT
AIRWAY
ELECTIVE
EMERGENCY
ELECTIVE
Old case of Hemi-mandibulectomy with forehead
flap with trismus for block dissection of neck nodes
Anesthesia of choice - G.A.
Intubating technique of
choice
?
MANAGEMENT PLAN
OF
UNANTICIPATED
DIFFICULT AIRWAY
7/16/2015
45
TheUnexpected DifficultAirway
 Experienced help may not be immediately available
 Special equipment may not be immediately
available
 A general anaesthetic has usually been
administered
 A long acting relaxant may have been given
 Backup airway management plans may be poorly
thought out
46
Take home message
 Be familiar with the alternative methods of intubating
technique and use it regularly in your day today
practice e.g. ILMA, FOB, Videolaryngoscopes,
cricothyroidotomy…………….
 So that you won’t fumble at the time of crisis
7/16/2015
47
GOOD LUCK
Challenges may
be
Waiting for you
7/16/2015
48
The whole world is made up of mistakes and
people
Forgive the mistakes and love the people
Thank you