Transcript The Difficult Airway

The Difficult Airway
Vanessa Fludder
Worthing Anaesthetics Department
Causes of a difficult airway
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Small mouth opening
Large tongue
Dentition
Big sticky out upper teeth
Small lower jaw
Immobility of head/neck/jaw
Beard
The Difficult Airway
- What exactly do we mean?
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Difficult Mask Ventilation
Difficult Laryngoscopy
Difficult Intubation
All Three!
Causes of a difficult airway
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Congenital
Infection
Trauma
Tumour
Endocrine
Body shape
Degenerative
Other
(inhaled foreign body, anaphylaxis)
Congenital
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Down’s Syndrome
Pierre Robin
Treacher Collins
Goldenhar’s
Hurler’s
Cleft Palate
Marfan’s
Klippel Feil
Down’s Syndrome
• Relatively large
tongue
• Small mandible
• Atlanto-axial
instability (20%)
• OSA is common
• Difficult intubation
• Smaller tube than
predicted
Pierre Robin
• Severe micrognathia
– (small mandible)
• Posterior prolapse of
tongue
• Difficult intubation
• Breathe better prone
or on side
• May need
tracheostomy
Goldenhar’s
• Facial Asymmetry
• Difficult intubation
Hurler’s
• Connective Tissue disorder
• Mucopolysaccharidosis
• Abnormal airway anatomy
• Difficult intubation
• Also have dwarfism,
cardiac failure
Infection
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Epiglottitis
Croup
Tonsilitis
Tonsilar/Peritonsilar abcesses
Dental abcess
Ludwig’s Angina
Tetanus
Epiglottitis
• Haemophilus
influenzae type B
• Adrenaline, heliox
and steroids may help
• Gas induction sevo in
100% oxygen
NB don’t do X-ray!
Ludwig’s Angina
Tracheostomy – Gold Standard?
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Distorted anatomy, swollen tissue.
Inability of patient to lie flat.
Mediastinal spread of infection
Aspiration of pus
• Recommended when retropharyngeal
space is involved (CT scan)
Awake Fibre-optic
Intubation
• May be more difficult due to copious
secretions which cannot be swallowed
• Very important to avoid airway irritation
and laryngeal spasm
• Probably the safest overall technique
Tetanus
Trauma
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C-spine injury
Facial trauma
Facial Burns
Inhalational injury
Post head/neck surgery/radiotherapy
Inhaled foreign body
C-spine injury
• Stable or Unstable?
• Management
• Most likely patient will be
in a hard collar
• Elective
• Awake fibre-optic
intubation
• Cannot move neck
• Associated injuries
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Emergency
RSI
Remove collar if need to
No evidence of damage
to neck by intubation
Facial Burns
• Oedema worsens rapidly and may increase in
1st 24hrs
• Consider intubation if
• Soot in nostrils or in mouth
• Burns to face
• Do RSI, early rather than late, and don’t cut ETT
Inhalational Injury
• Airway oedema and obstruction
• Lung damage – ARDS
• Consider intubation if
– Voice changes
– Carboxyhaemoglobin levels > 15%
– CXR ranges
– Deteriorating ABGs
Inhaled foreign body
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Tend to be young
Object may not be radio-opaque
May push object further down by IPPV
Dex/Adren to reduce swelling
Inhalational induction
ENT surgeon
Ventilating rigid bronchoscope
Tumours
Airway tumours
• Pharyngeal
• Supraglottic
• Glottic
• Subglottic
• Check nasendoscopy
pictures
• Look at CT scans
• Discuss with surgeon
• Change in voice
• Difficulty breathing
• Difficulty swallowing
• Stridor
Airway Tumours
• Supra-glottic
– Cricothyroid cannula
– FOI asleep or awake
• Sub-glottic
– Laryngoscopy usually OK
– Will need smaller ETT
Endocrine
• Diabetes Mellitis
• Acromegally
• Thyroid Goitre
Diabetes Mellitis
• One third of IDDMs have a difficult airway!
– ? Due to glycosylation of tissue proteins
• Limited joint mobility
• Limited atlanto-occipital movement
• (Prayer sign)
Acromegally
• Enlarged facial features (Mask Ventilation
can be difficult)
• Overgrowth of soft tissue in airway
– Enlarged tongue
– Enlarged epiglottis
– Smaller glottic aperture
Goitre
Degenerative/Autoimmune
• Ankylosing Spondylitis
• Rheumatoid Arthritis
• Scleroderma
Ankylosing Spondylitis
• Decreased mobility of
whole spine
• Fixed flexion
deformity of head and
neck
• Some have limited
mouth opening too
due to flexed position
of head
• Consider
– Type and length of
operation
– Risk of aspiration
– Possibility of regional
anaesthetic
– May not have a
problem with mask
ventilation, or LMA
– FOI asleep or awake
Rheumatoid Arthritis
• TMJ ankylosis
• Limited c-spine movement
• Cricoarytenoid arthritis
What to do?
• ‘Keep in mind that the discomfort of
an intubation or the deformity of a
tracheostomy will be forgiven much
more readily than an anoxic event
that occurs during the chaos of an
emergency airway crisis’ WW shockley
Body Shape
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Obesity
Pregnancy
Beards!
Dentition
Pregnancy
• Increased risk of aspiration
• Increased airway tissue oedema
• Friable mucous membranes – liable to
bleed
• Enlarged Breasts
• Complicated by Increased BMR, and
decreased FRC and oxygen reserve
Management of Pregnant
Woman
• Avoid GA!
• Antacid and prokinetc (ranitidine +
maxalon +/- Sodium citrate)
• Optimum positioning
• Good pre-oxygenation
• RSI
• Short handled blade
• Don’t panic!
Avoiding Airway Problems
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Correct Positioning
Proper equipment and preparation
Proper pre-op assessment
Plans A, B, C, D
Call for senior help 
Avoiding Airway Problems
• Avoid GA!
– Local infiltration
– Local block
– Regional block
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Avoid traumatising the airway (BCMDI)
Glycopyrolate
Emergency Drugs
Pre-Oxygenate properly
Management Plan A
• If no risk of aspiration
• If mask ventilation predicted not to be difficult
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iv induction
Check mask ventilation
Direct laryngoscopy
Limited gentle attempts (ABCD)
Asleep FOI or LMA
Management Plan B
• Risk of aspiration deemed to be significant
• Awake FOI
– Glycopyrolate 200mcg 15 mins pre-op
– Co-phenylcaine to nostrils
– NIBP, ECG, SpO2
– Oxygen (nasal cannula)
– Epidural catheter in working channel, SAYGO
– Prepare equipment and mount ETT B4 start
Awake cricothyroid cannula