The Dif fi cult Airway

Transcription

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2 The Difficult Airway

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4 David B. Glick, MD, MBA Richard M. Cooper, B.Sc, M.Sc, MD, FRCPC Andranik Ovassapian, MD Editors The Difficult Airway An Atlas of Tools and Techniques for Clinical Management

5 Editors David B. Glick, MD, MBA Department of Anesthesia & Critical Care The University of Chicago Chicago, IL, USA Andranik Ovassapian, MD (deceased) Department of Anesthesia & Critical Care The University of Chicago Chicago, IL, USA Richard M. Cooper, B.Sc, M.Sc, MD, FRCPC Department of Anesthesia University of Toronto Department of Anesthesia and Pain Manage ment Toronto General Hospital Toronto, ON, Canada ISBN ISBN (ebook) DOI / Springer New York Heidelberg Dordrecht London Library of Congress Control Number: Springer Science+Business Media New York 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (

6 To our loving wives and wonderful children, and to the memory of Dr. Andranik Ovassapian pioneer, mentor, colleague, and friend to a generation of physicians and nurses the world over. David B. Glick Richard M. Cooper

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8 Preface Few challenges can sour faster or lead to more devastating outcomes than failed attempts to control a dif fi cult airway. Things can go from calm to catastrophic in little more than the time that you are able to hold your breath, and death or profound neurologic injury are the possible results. The concerns regarding the management of dif fi cult airways are shouldered by many in the healthcare fi eld as anesthesiologists, intensive care physicians, emergency room physicians, as well as nurses in many different venues, and out-of-hospital fi rst responders may all be tasked with providing airway support and/or de fi nitive airway control to a wide range of patients. Unfortunately, the majority of patients with airways that are dif fi cult to manage are either unsuspected dif fi cult airways or require urgent airway management. Either way, there is often precious little time to develop a plan for how best to approach the problem. The American Society of Anesthesiologists Dif fi cult Airway Algorithm, and algorithms like it, were developed in large part to offer a pre-planned approach to the dif fi cult airway to streamline the efforts from the time of identifying the dif fi cult airway to successful management of the airway. The advantage of the ASA algorithm is that it includes many different techniques and tools to help the provider overcome the entire gamut of airway challenges. The drawback to the wide range of approaches is that it poses a signi fi cant experiential challenge to the airway manager who wants to become familiar with the many options available to manage a dif fi cult airway. This problem has been exacerbated by the rapid evolution in airway management tools and the techniques for their use that have occurred in the past years. Our purpose in writing The Difficult Airway was to provide the necessary background and instructions in the many techniques listed in the ASA algorithm so that any practitioner, from the novice to the seasoned veteran, will feel comfortable in selecting and practicing unfamiliar techniques and devices or better appreciate the role that familiar ones might play. To this end, we have bene fi tted greatly from the experiences and expertise of an international collection of practitioners who have each written and illustrated a chapter covering techniques that they, in many cases, have pioneered. Much of the inspiration for this work as well as the selection of the authors for each of the chapters came from Dr. Andranik Ovassapian. Dr. Ovassapian s groundbreaking work with fi beroptic bronchoscopy and his involvement in the founding and early leadership of the Society for Airway Management has served as the foundation for much of the work that has followed regarding the management of the expected and unexpected dif fi cult airway. For that, a generation of clinicians and their patients owe him a tremendous debt. We were all deeply saddened by his death during the writing of this book, but trust that the lessons he taught us will continue to improve patient safety and satisfaction for many years to come. vii

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10 Acknowledgements First and foremost, we would like to thank all the authors who generously shared their time and their experience in preparing the chapters for The Difficult Airway. We would also like to thank Joni Fraser, our developmental editor, who tirelessly pursued all the loose ends that any project of this kind inevitably has and made sure that everything came together properly; our assistant editor, Joanna Perey, who managed the communications with the artists and editors at Springer; and Shelley Reinhardt, our senior editor, who took over the project while it was still in its earliest stages and navigated us through a string of challenges and changes that made it possible for our vision for this book to become a reality. ix

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12 Contents Preface... Acknowledgements... Contributors... vii ix xvii 1 The Difficult Airway: Definitions and Algorithms... 1 Zdravka Zafirova and Avery Tung Introduction 1 Definitions 2 Incidence 3 Algorithms for Addressing the Difficult Airway 4 Conclusion 9 References 9 2 The Expected Difficult Airway Satya Krishna Ramachandran and Sachin Kheterpal Introduction 12 Anatomy of the Difficult Airway 12 Factors Affecting Tongue-Pharyngeal Volume Disproportion 13 Factors Affecting Access to the Upper Airway 13 Factors Affecting Laryngoscopic Visualization Vector 14 Factors Affecting Laryngeal Structures 19 Anatomy and Physiology of the Compromised and Critical Airway 19 Clinical Assessment of the Airway 21 Systemic Conditions 22 Airway Tumors 23 Upper Airway Infections 25 Specific Airway Assessment 26 Measures of Tongue-Pharyngeal Volume Disproportion 26 Measures of Laryngoscopic Visualization Vector 27 Other Airway-Related Tests 27 xi

13 CONTENTS Clinical Prediction of the Difficult Airway 28 Clinical Prediction of Difficult Intubation 28 Clinical Prediction of Difficult Mask Ventilation 29 Difficult Mask Ventilation Combined with Difficult Intubation 29 Clinical Prediction of Need for Awake Surgical Airway 29 Summary 30 References 30 3 The Role of Awake Intubation P. Allan Klock Jr. Introduction 33 Indications for Awake Intubation 35 Contraindications to Awake Intubation 36 Advantages of Awake Tracheal Intubation 36 Keys to Successful Awake Intubation 37 Psychological Preparation 37 Dry the Airway 37 Supplemental Oxygen 37 Anxiolysis and Sedation 38 Anesthesia of the Airway 38 Applied Airway Anatomy 39 Topical Anesthesia of the Tongue 39 Intubating the Trachea 45 References 46 4 Unanticipated Difficult Direct Laryngoscopy: Methods to Improve Its Success Mark E. Nunnally and Michael R. Hernandez Introduction 48 Lingual Tonsil Hyperplasia 49 Copious Blood and Secretions 49 Blades 49 Shape 49 Construction 52 Lights 52 Adjuncts to Direct Laryngoscopy 53 Stylets and Introducers 53 Laryngoscope Optical Modifications 54 Technique of Direct Laryngoscopy 54 Sniffing Position 55 Head Extension 55 Neck Flexion 55 Obesity and the Sniffing Position 56 Laryngeal Manipulation 56 Cervical Spine Injury 58 Techniques for Difficult Laryngoscopy 59 Complications 60 Conclusion 60 References 60 xii

14 CONTENTS 5 The Role of Rigid Fiberoptic Laryngoscopes Richard M. Cooper Introduction 65 Limitations of Direct (Line-of-Sight) Laryngoscopy 66 Rigid Fiberoptic Laryngoscopes 66 UpsherScope 67 WuScope 67 Bullard 68 Truview EVO2 73 Conclusion 74 References 74 6 Role of Rigid Video Laryngoscopy Richard M. Cooper and Corina Lee Introduction 77 Channeled Scopes 78 Airtraq 78 Pentax AWS Non-channeled Scopes 87 GlideScope Video Laryngoscope (GVL ) 87 Visualization 92 ETT Delivery 93 ETT Advancement 94 Clinical Applications 95 McGrath Series 5 99 Clinical Applications 101 Video Macintosh/C-MAC 102 Conclusion and Future Directions 106 References The Role of the Supraglottic Airway Irene P. Osborn Introduction 113 Basic Use 115 The LMA as a Rescue Device 117 Flexible Bronchoscopic Intubation Via the SGA 117 Other Supraglottic Airways for Intubation 119 Awake Placement of the Laryngeal Mask 120 The Intubation LMAs (Fastrach and CTrach ) 121 The Intubating LMA (Fastrach ) 121 LMAs with Gastric Access 125 The LMA ProSeal 125 LMA Supreme 126 Intubating Through LMAs (Classic, Supreme, and ProSeal: Using the Aintree Intubation Catheter) 128 Conclusion 129 References 130 xiii

15 CONTENTS 8 The Role of Flexible Bronchoscopy David B. Glick Introduction 134 Equipment Necessary for Fiberoptic Intubation 134 Additional Supplies Necessary for Flexible Bronchoscopy 137 The Intubating Airway 137 Other Common Contents of the Cart 137 Setting up for Fiberoptic Intubation 138 Techniques for Fiberoptic Intubation 138 Asleep Oral Intubation 138 Asleep Nasal Intubation 145 Awake Fiberoptic Intubation 149 Awake Oral Fiberoptic Intubation 149 Awake Nasal Fiberoptic Intubation 151 Fiberoptic Bronchoscopy in Combination with Other Airway Management Techniques 152 Fiberoptic Intubation Through the Laryngeal Mask Airways 154 Complications Associated with Fiberoptic Intubations 158 References The Role of Optical Stylets Richard Levitan Introduction 162 Design Variation 162 Principles of Optical Stylets and Progressive Visualization 166 Patient Positioning 169 Tube Tip Design and Relevance to Optical Stylets 169 Mechanics and Tube Delivery Issues 170 Oxygen Ports 171 Cleaning 171 Combining Optical Stylets with Supraglottic Airways 171 Specific Uses of the Different Instruments, Pediatric Versions 172 Literature Reports of Optical Stylets 172 Bibliography 173 General or Multi-device Review 173 Bonfils 173 Levitan 174 Shikani 174 Manufacturer s Web Sites 175 xiv 10 The Role of the Lightwand Ashutosh Wali Introduction 177 Principle 179 Assembly and Positioning 179 Method 180 Orotracheal Intubation 180 Nasotracheal Intubation 182 Literature Review 185 Indications 188 Problems 188 Conclusion 188 References 189