Transcript AICU-C-2_Airway - Thomas Jefferson University

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Airway Management
Mehdi Khosravi, MD Pulmonary/CCM Fellow
Giuditta Angelini, MD Assistant Professor
Jonathan T. Ketzler, MD Associate Professor
Douglas B. Coursin, MD Professor
Departments of Anesthesiology & Medicine
University of Wisconsin, Madison
Global Assessment
• Assess underlying need for airway control
– Duration of intubation
– Permanent support
– Temporary support
Slide 3
Global Assessment
• Pathophysiology of the respiratory failure
– Hypoxic respiratory failure
– Hypercapnic respiratory failure
• Assessment
• Code status should be clarified prior to proceeding.
Slide 4
Global Assessment
• Oxygenation
– Respiratory rate and use of accessory muscles
– Amount of supplemental oxygen
– Pulse oximeter or arterial blood gas
Slide 5
Global Assessment
• Airway
– Anatomy
– Patency
– Airway device in place
Slide 6
Oxygen Delivery Devices
(In order of degree of support)
• Nasal Cannula
• Face tent
• Ventimask
• Nonrebreather mask
Slide 7
Oxygen Delivery Devices
Noninvasive Positive Pressure
• CPAP is a continuous positive pressure
• BiPAP allows for an inspiratory and expiratory pressure
to support and improve spontaneous ventilation
Slide 8
Oxygen Delivery Devices
Noninvasive Positive Pressure
• Consider when to intubation
• Patient status
• Device considerations:
– Some devices allow respiratory rate to be set.
– Up to 10 L of oxygen can be delivered into the mask
for 100% oxygen delivery.
– Nasal or oral (full face) mask can be used; less
aspiration potential with nasal.
Slide 9
Degree of Respiratory Distress
• Respiratory pattern
• Need for artificial airway
• Pulse oximetry
• Arterial blood gas
Slide 10
Temporizing Measures
• Naloxone for narcotic overdose
– 40 mcg every minute up to 200 mcg
– 0.4 - 2 mg of naloxone is indicated in patients with
respiratory arrest and history suggestive of narcotic
overdose
– Caution in patients with history of narcotic
dependence
– Naloxone drip can be titrated starting at half the bolus
dose used to obtain an effect
Slide 11
Temporizing Measures
• Flumazenil for benzodiazepine overdose
• Artificial airway for upper airway obstruction in patients
with oversedation
• 100% oxygen and maintenance of spontaneous
ventilation in patients with pneumothorax
Slide 12
Oral/Nasal Airways
Slide 13
Indications for Intubation
• Depressed mental status
– Head trauma patients with GCS 8 or less is an
indication for intubation
– Drug overdose patients may require 24 - 48 hours
airway control.
• Upper airway edema
– Inhalation injuries
– Ludwig’s angina
– Epiglottitis
Slide 14
Underlying Lung Disease
• Chronic obstructive lung disease
• Pulmonary embolus
• Restrictive lung disease
Slide 15
Airway Anatomy - Difficult
Intubation
• Length of upper incisors and overriding maxillary teeth
• Interincisor distance < 3 cm
• Thyromental distance < 7 cm
• Neck extension < 35 degrees
• Sternomental distance < 12.5 cm
• Narrow palate (less than three finger breaths)
• Mallampati score class III or IV
• Stiff joint syndrome
Erden V, et al. Brit J Anesth. 2003;91:159-160.
Slide 16
Prayer Sign
Mallampati Score
Den Herder, et al.
Laryngoscope. 2005: 115(4):
735-739
Class I:
Uvula/tonsillar pillars visible
Class II: Tip of the uvula / pillars hidden by tongue
Class III: Only soft palate visible
Class IV: Only hard palate visible
Slide 17
Comorbidities
• Potential for aspiration requires rapid sequence
intubation with cricoid pressure
• Potential for hypotension
• Organ failure
Slide 18
Induction Agents
• Sodium Thiopental
– 3 - 5 mg/kg IV
• Etomidate
– 0.1 - 0.3 mg/kg IV
• Propofol
– 2 - 3 mg/kg IV
• Ketamine
– 1 - 4 mg/kg IV, 5 - 10 mg/kg IM
Slide 19
Neuromuscular Blockers
• Succinylcholine
– 1 - 2 mg/kg IV, 4 mg/kg IM
• Rocuronium
– 0.6 - 1.2 mg/kg
• Vecuronium
– 0.1 mg/kg
• Cisatricurium
– 0.2 mg/kg
Slide 20
Rapid Sequence Intubation
• Preoxygenate for three to five minutes prior to induction
• Crycoid pressure should be applied from prior to
induction until confirmation of appropriate placement.
• Succinylcholine 1 - 2 mg/kg
• Rocuronium 1.2 mg/kg
• Avoid mask ventilation after induction.
Slide 21
Y BAG PEOPLE
(Reference #6)
Slide 22
Cricoid Pressure
• Cricoid is circumferential
cartilage
• Pressure obstructs
esophagus to prevent
escape of gastric
contents
• Maintains airway patency
Koziol C, et al. AORN. 2000;72(6):1018-1030.
Slide 23
Sniffing Position
Align oral, pharyngeal, and laryngeal axes to
bring epiglottis and vocal cords into view.
Hirsch N, et al.
Anesthesiology.
2000;93(5):1366.
Slide 24
Mask Ventilation
• Mask ventilation crucial in
patients who are difficult
to intubate
Slide 25
Laryngoscope Blades and
Endotracheal Tubes
Mac blade: End of blade should be placed in front of epiglottis in valecula
ETT for Fastrach LMA
Pediatric uncuffed ETT
ETT for blind nasal
Standard ETT
Miller blade: End of blade should be under epiglottis
Slide 26
Graded Views on Intubation
Grade 1: Full glottis visible
Grade 2: Only posterior commissure
Grade 3: Only epiglottis
Grade 4: No glottis structures are visible
Yarnamoto K, et al. Anesthesiology. 1997;86(2):316.
Slide 27
Confirmation of Placement
• Direct visualization
• Humidity fogging the endotracheal tube
• End tidal CO2 which is maintained after > 5 breaths
• Refill in 5 seconds
• Symmetrical chest wall movement
• Bilateral breath sounds
• Maintenance of oxygenation by pulse oximetry
• Absence of epigastric auscultation during ventilation
Slide 28
Additional Considerations
• Additional personnel and an experienced provider as
backup
• Suction available
• No a muscle relaxant if difficult mask ventilation is
demonstrated or expected
• Awake intubation should be considered
Slide 29
American Society of
Anesthesiologists
www.asahq.org
Slide 30
Alternative Methods
• Blind nasal intubation
• Eschmann stylet
• Fiber optic bronchoscopic intubation
• Laryngeal mask airway
• Light wand
• Retrograde intubation
• Surgical tracheostomy
• Combitube
Slide 31
Eschman Stylet
• Use if Grade III view
achieved
• Perform direct laryngoscopy
• Place Eschman where
trachea is anticipated
• Feel tracheal rings against
stiffness of stylet
• Thread 7.0 or 7.5 ETT over
stylet with laryngoscope in
place
Slide 32
Fiberoptic Scope
Fiberoptic Scope is used
• For bronchoscopy
• To thread an endotracheal
tube into the trachea
• Via laryngeal mask airway
in place
Slide 33
The Laryngeal Mask Airway (LMA)
Slide 34
LMA Placement
LMA Placement:
• Guide along the palate
• Position underneath the
epiglottis, in front of the
tracheal opening, with the
tip in the esophagus
Martin S, et al. J Trauma Injury, Infection
Crit Care. 1999;47(2):352-357.
• FOB placement through
LMA positions in front of
trachea
Slide 35
The FastrachTM Laryngeal
Mask Airway
• Reinforced LMA allows
for passage of ETT
without visualization of
trachea.
• 10% failure rate in
experienced hands
• 20% failure rate in
inexperienced
Slide 36
The Light Wand
Light wand:
• Transillumination of
trachea
• Minimal complication
Contraindications:
• tumors, trauma, or foreign
bodies of upper airway
Slide 37
Retrograde Intubation
• Puncture of the
cricothyroid membrane
with retrograde passage
of a wire to the trachea
• Endotracheal tube guided
endoscopically over the
wire through the trachea
Wesler N, et al. Acta Anaes Scan.
2004;48(4):412-416.
Slide 38
Combitube
Use:
• Emergency airway
Confirmation of Ventilation:
• blind blue tube
• white (clear) tube with patent
distal end
Slide 39
Combitube
Prevent airway edema/trauma:
• Changed to endotracheal tube (ETT) or tracheostomy
Problems:
• Located in esophagus
• Failed exchange attempt
Slide 40
Tracheostomy
• Surgical airway through
the cervical trachea
• Risks
• Caution
Sharpe M, et al. Laryngoscope.
2003;113(3):530-536.
Slide 41
Case Studies
The following are case studies / review questions that can
be used for review of this presentation
Cases Studies
Review Questions
Skip All
Case Scenario #1
• The patient is 70 kg with a 20-year history of diabetes.
• On exam, the patient has intercisor distance of 4 cm,
thyromental distance is 8 cm, neck extension is 45
degrees, and mallampati score is 1.
• Your staff wants to use thiopental and pancuronium.
• Do you have any further questions for this patient or
would you proceed with your staff?
Slide 43
Case Scenario #1 - Answer
• A diabetic for 20 years needs assessment for stiff joint
syndrome.
• You should have the patient demonstrate the prayer
sign.
• If the patient is unable to oppose their fingers, you
should not give pancuronium.
• You may want to proceed with an LMA and FOB at your
disposal.
• If the patient has a history of gastroparesis, you may
want to consider an awake FOB.
Slide 44
Case Scenario #2
• 43-year-old patient with HIV, likely PCP pneumonia who
had been prophylaxed with dapsone
• RR is 38, oxygen saturation is 90% on 100% NRB mask
• The patient is on his way to get a CT scan.
• Is it appropriate to proceed without intubation?
Slide 45
Case Scenario #2 - Answer
• Dapsone will produce some degree of
methemoglobinemia.
• Therefore, some degree of desaturation may not be
overcome.
• The patient is in significant respiratory distress and will
be confined in an area without easy access.
• Intubation should be considered as an extra measure of
safety, especially as this patient is likely to get worse.
Slide 46
Case Scenario #3
• 40-year-old, 182-kg man has a history of sleep apnea
and systolic ejection fraction of 25%. He has a Strep
pneumonia in his left lower lobe and progressive
respiratory insufficiency.
• He extends his neck to 50 degrees and has a mallampati
score of 2.
• Would you proceed with an awake FOB?
Slide 47
Case Scenario #3 - Answer
• The patient’s airway anatomy is not
suggestive of difficulty.
• However, with supine position, subcutaneous
tissue may impair your ability to visualize or
ventilate.
• Use of gravity, including a shoulder roll,
extreme sniffing position, and reverse
trendelenburg may be helpful with asleep DL.
• Prudent to have some accessory equipment,
including an LMA and FOB, for back up
Slide 48
Review Questions
The following are case studies / review questions that can
be used for review of this presentation
Cases Studies
Review Questions
Skip
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References
• Caplan RA, et al. Practice guidelines for management of the difficult
airway. Anesthesiology. 1993;78:597-602.
• Langeron O, et al. Predictors of difficult mask ventilation.
Anesthesiology. 2000;92:1229-36.
• Frerk CM, et al. Predicting difficult intubation. Anaesthesia.
1991;46:1005-08.
• Tse JC, et al. Predicting difficult endotracheal intubation in surgical
patients scheduled for general anesthesia. Anesthesia & Analgesia.
1995;81:254-8.
• Benumof JL, et al. LMA and the ASA difficult airway algorithm.
Anesthesiology. 1996;84:686-99.
• Reynolds S, Heffner J. Airway management of the critically ill
patient. Chest. 2005;127:1397-1412.
Slide 51