Diagnosis & Management of the Difficult Airway

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1 Diagnosis & Management of the Difficult Airway Dr. E. Rawlings Plymouth Anaesthetic Department Complications of Airway Management Medicolegal Serious morbidity Mortality

2 Complications of Airway Management Medicolegal Serious morbidity Mortality NCEPOD :3 anaesthetic deaths Failure of intubation Management of difficult airway Predict Difficulties Mask ventilation & Intubation

3 Management of difficult airway Predict Difficulties Mask ventilation & Intubation Safe management Difficult airway Management of difficult airway Predict Difficulties Mask ventilation & Intubation Safe management Difficult airway Anticipated Not anticipated

4 Difficult airway? Difficult intubation! Difficult face mask inflation! Imprecise & not helpful Difficult Intubation ASA Definition Practitioner - 2 year s More than three attempts full at time laryngoscopy conventional training in anaesthesia Longer than 10 minutes

5 Difficult Laryngoscopy Cormack R.S. & Lehane J. Anaesthesia 1984 Conventional laryngoscope Grade 1 Grade 2 Grade 3 Grade 4

6 Failed intubation General population 1:2230 Obstetric patients 1:280-1:750 Difficult mask ventilation Unassisted anaesthetist unable to maintain oxygen saturation above 90% using 100% oxygen (patient with preoperative saturation greater than 90%)

7 ASA guidelines Evaluation of the airway Preparation Strategy for intubation difficulty Clear plan of action Strategy for extubation Follow-up Preventing crisis Pre-operative assessment Routine pre-oxygenation CLEAR PLAN OF ACTION

8 Anaesthetist Inexperienced Pitfalls Inappropriate technique Skilled & dedicated assistance Available Avoid persistent attempts at intubation Pre-oxygenation ROUTINE Recognised difficult intubation Obesity Risk of vomiting - RSI High risk-cardiac/respiratory

9 Pre-oxygenation? Washes out nitrogen FUNCTIONAL RESIDUAL CAPACITY All All patients at risk from from AIRWAY CATASTROPHE!! AIRWAY CATASTROPHE!! History Airway assessment identify previous difficulties Clinical examination General Head & neck Further investigations

10 Assessment Head & neck Anatomical Individual variation Short, muscular neck Prominent upper incisors Receding mandible Narrow mouth, high arched palate Limited mandibular movement

11 Jaw movement Mouth opening 3 fingers 4 cms. Jaw protrusion

12 Mallampati i Cervical movement General Range from full extension to full flexion >90 O Sniffing the morning air Atlanto-occipital Delikan s sign

13 Delikan s sign Thyromental normal distance > 6 cm

14 Other tests X-rays CT MRI Evaluation by ENT surgeon Nasendoscopy Tumour Conditions associated with airway difficulty Congenital Acquired

15 Congenital Pierre Robin Treacher Collins Goldenhar syndrome Klippel-Fiel Pierre-Robin Syndrome

16 Treacher Collins Syndrome Goldenhar Syndrome

17 Goldenhar Syndrome Acquired Restricted jaw opening Trismus dental abscess Tempero-mandibular joint restricted movement Facial fractures

18 Temporomandibular joint disease Neck Restricted movement Osteoarthritis Ankylosing spondylitis Instability Cervical spinal injury Rheumatoid arthritis

19 Ankylosing spondylitis Soft tissue Swelling Infection bleeding Burns Tumour Contractures Post burns Radiotherapy

20 Oral cancer surgery & radiotherapy Body weight Morbid obesity 120kg. + Excessive weight gain pregnancy

21 Predicted difficulty SEEK HELP Never use muscle relaxants until airway fully established! Planning

22 Is intubation required? Alterative techniques Mask/airway LMA Regional blockade Some patients Intubation mandatory Techniques for improving success

23 Direct Laryngoscopy Macintosh blade Oral cavity Pharynx & Larynx in line

24 BURP Optimal external laryngeal manipulation Back up & right pressure Railroading Gum elastic bougie & small ET tube

25 McCoy Laryngoscope McCoy laryngoscope

26 Polio blade Magill laryngoscope

27 Plan A Best attempt at laryngoscopy 22 person bag & mask

28 Plan A Best attempt at laryngoscopy Plan B Back up plan Optimum best attempt Experienced anaesthetist Optimal position of head Optimal external laryngeal manipulation One change of blade length Once change of blade type

29 Anticipated difficult airway Anticipated difficult airway Awake fibreoptic intubation

30 Awake fibre optic intubation Able to maintain own airway Fibreoptic intubation Unsuitable Severe airway obstruction Stridor Blood in airway

31 Fibreoptic intubation Anticipated difficulty Awake intubation not feasible Intubate under GA

32 Anticipated difficulty Awake intubation not feasible Intubate under GA

33

34 Intubating LMA

35 Intubating Laryngeal mask airway

36 Failure to intubate & ventilate!! Anaesthetist s worst nightmare Surgical cricothyroidotomy

37 Needle cricothyroidotomy

38 Jet-Ventilation Catheter

39 Quicktrach

40 Difficult Airway Society UK Guidelines UK Guidelines Abandon evidence-basis Promoting techniques for Promoting techniques as sole determinant Narrowing down intubation which Only techniques occur visually guidedallow techniques/devices used concurrent Establish a ventilation core repertoire in training syllabus

41 Plan A: Initial tracheal Intubation plan UK guidelines

42 UK guidelines Initial Plan tracheal A: Intubation plan Direct laryngoscopy Succeed Tracheal intubation UK guidelines Initial Plan tracheal A: Intubation plan Direct laryngoscopy Succeed Tracheal intubation Failed intubation

43 UK guidelines Secondary Plan B: tracheal Intubation plan ILMA or LMA Succeed Confirm UK guidelines Secondary Plan B: tracheal Intubation plan ILMA or LMA Succeed Fibreoptic tracheal intubation Confirm through ILMA or LMA Failed oxygenation

44 UK guidelines Maintainance of oxygenation, ventilation, Plan C: postponement of surgery & awakening of patient Revert to face mask Oxygenate & ventilate Succeed Postpone surgery Awaken patient Failed oxygenation UK guidelines Rescue techniques for can t Plan t intubate D: can t t ventilate situation,

45 UK guidelines Rescue techniques for can t Plan t intubate D: can t t ventilate situation, Optimize mask technique O2 ++ Awaken patient UK guidelines Rescue techniques for can t Plan t intubate D: can t t ventilate situation, Optimize mask technique Increasing hypoxaemia O2 ++ Awaken patient LMA O2++

46 UK guidelines Rescue techniques for can t Plan t intubate D: can t t ventilate situation, Optimize mask technique Increasing hypoxaemia O2 ++ Awaken patient LMA O2++ Increasing hypoxaemia!!! UK guidelines Increasing hypoxaemia or Cannula cricothyroidotomy Stab cricothyroidotomy fail

47 Post-operative Airway traumatised Repeated attempts at intubation Surgical intervention High risk Oedema and airway obstruction Extubation Awake Post operative ventilation

48 Document problems Patients notes General practitioner Patient information Verbal Written Training airway management

49 S. West Trainees (Local teaching) Module for Specialist Registrars Fibreoptic Workshop

50

51

52 National DAME Cardiff Oxford Torbay airway day Difficult Airway Society Any questions?

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