Dr.Bharghavi.M 2 nd year post graduate Dept of Anaesthesia
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1 DIFFICULT AIRWAY CANNOT VENTILATE, CANNOT INTUBATE. Dr.Bharghavi.M 2 nd year post graduate Dept of Anaesthesia
2 Difficult airway According to AMERICAN SOCIETY OF ANAESTHESIOLOGISTS Difficult Airway is defined as, A clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation or both. It includes: Difficult mask ventilation Difficult Laryngoscopy Difficult intubation.
3 DIFFICULT MASK VENTILATION It is not possible for the anaesthesiologist to maintain SpO 2 >90% using 100% Oxygen after induction and positive pressure mask ventilation in a patient whose SpO 2 was > 90% before anaesthetic intervention
4 SIGNS OF INADEQUATE MASK VENTILATION : Absent or inadequate chest movement. Absent breath sounds. Gastric air entry or dilatation. Cyanosis. Haemodynamic changes due to hypoxia or hypercarbia. Decreasing oxygen saturation. Absent or inadequate exhaled CO2
5 DIFFICULT LARYNGOSCOPY : It is not possible to visualize any portion of the vocal cords with conventional laryngoscopy. DIFFICULT ENDOTRACHEAL INTUBATION : Using conventional laryngoscopy, it requires >3 attempts to insert an ETT by an experienced anaesthesiologist
6 CAUSES OF DIFFICULT INTUBATION Patient : Congenital & acquired causes. Anaesthesiologist : Inadequate preoperative assessment Inadequate equipment preparation Inexperience Poor technique Equipment : Malfunction / Unavailability
7 ASSESSMENT OF DIFFICULT AIRWAY History Individual indices Group indices - Wilson s score - Lemon assessment Radiological assessment
8 HISTORY Congenital airway abnormalities: Pierre robin syndrome, Treachercollin s syndrome, Down s syndrome etc. Acquired: Infections of Larynx, Rheumatoid arthritis, Acromegaly, tumors of tongue and larynx. Facial trauma, Obesity, Burns etc., Iatrogenic: Oral/pharyngeal radiotherapy, Laryngeal/tracheal surgery, TMJ surgery.
9 Individual indices Assessment of TMJ function : Inter incisor gap with maximal mouth opening of > 5cm / or admits 3 fingers of the patient Significance : easy insertion of 3cm deep flange of laryngoscope blade <3cm : difficult laryngoscopy <2cm : difficult LMA insertion Affected by TMJ and upper cervical spine mobility
10 Assessment of cervical and AOJ function : Flexion of cervical spine and extension of atlanto occipital joint Asking patient to touch his Manubrium sterni with his chin to assess neck flexion. Asking patient to look at ceiling with out raising eyebrows to assess AO joint function.
11 MODIFIED MALLAMPATI (MMP) GRADING Grade 1 Faucial pillars, uvula, soft palate Grade 2 Uvula,soft palate visible Grade 3 Base of uvula, soft palate Grade 4 soft palate not visible Patient in sitting position Head in neutral position Maximal tongue protrusion
12 MMP GRADE ZERO Visualisation of any part of epiglottis during MMP test Associated with easy laryngoscopy Difficult airway possible Large epiglottis hinder laryngoscopic view.
13 ASSESSMENT OF MANDIBULAR SPACE THYROMENTAL DISTANCE : Distance from the tip of thyroid cartilage to the tip of inside of the mentum. >6.5 cm No problem with laryngoscopy & intubation <6.5 cm Difficult laryngoscopy
14 HYO MENTAL DISTANCE Distance between mentum and hyoid bone Grade I : > 6cm Grade II: 4 6cm Grade III : < 4cm Impossible laryngoscopy & Intubation
15 STERNOMENTAL DISTANCE Distance from the upper border of the manubrium to the tip of mentum Measured with head in full extension and mouth closed >12.5cm predicts normal laryngoscopic intubation Single best predictor for laryngoscopic intubation`
16 CORMACK - LEHANE GRADING AT DIRECT LARYNGOSCOPY Grade I: visualization of entire vocal cords Grade IIa: visualization of posterior part of vocal cords Grade IIb: visualization of arytenoids only Grade IIIa: epiglottis liftable Grade IIIb: epiglottis adherent or only tip visible Grade IV : no glottic structures seen.
17 Group indices - Wilson s score Total score of 10 : score <5 = easy laryngoscopy score 6-7 = moderate difficulty 8-10 = severe difficulty
18 LEMON ASSESSMENT L - Look externally (facial trauma, large incisors, beard, large tongue) E - Evaluate rule 3 - Inter incisor gap 3 - Hyo-mental distance 2 - Distance between thyroid cartilage and floor of the mouth(thyrohyoid). M- Modified Mallampati score O - Obstruction N - Neck mobility.
19
20 Radiological assessment X-ray neck cervical spine Occiput - C1 spinous process distance < 5mm C 1 C 2 gap < 5mm Tracheal compression /deviation Mandibular length / depth ratio
21 Difficult bag mask ventilation Assessment for Difficult supra glottic airway BONES Bearded individuals Obese individuals No teeth Elderly Snorers RODS Restricted mouth opening Obstructed upper airway Disrupted upper airway Stiff lungs
22 RAPID AIRWAY ASSESSMENT Applicable in emergency situations Time taken <15 sec Rule of Ability to insert one finger infront of the tragus for assessment of TMJ Minimum two finger breadth opening of the mouth Three finger breadth submandibular space Architecture of teeth
23 UPPER LIP BITE /CATCH TEST (RAPID AIRWAY ASSESSMENT)
24 Equipment for the Difficult airway cart MANDATORY Manual self inflating bag Airway exchange catheter Working laryngoscopes with Cricothyroidotomy kit Macintosh blades Supra glottic airway device Face masks /intubating SAD ETTs Tracheostomy kit. Magill forceps DESIRABLE McCoy laryngoscope blades Stylet Video laryngoscope Bougie Flexible fibre-optic Oropharyngeal airway and bronchoscope nasopharyngeal airway Equipment for high-flow nasal Nasogastric tube oxygenation.
25 Cannot Ventilate,Cannot Intubate (CVCI) Cannot ventilate, cannot intubate situation Incidence- 1 in 10,000 ( %)
26 How to manage? CALL FOR HELP Using two hands to hold the mask and an assistant to squeeze the bag may make a significant difference Do not persist with intubation attempts, limit to 3
27 MANAGEMENT OF CVCI
28 Surgical Airway
29 Unable to intubate Re-establish mask ventilation Ensure optimal positioning (sniffing ) Consider using a different blade LMA Alternative techniques Awaken the patient Surgical Airway
30 Oral and nasal airway Oro pharyngeal airway Nasopharyngeal airway bypasses obstruction at the level of the soft palate LMA, Combitube
31 Mask ventilation Although tracheal intubation is the ultimate goal in airway management, the ability to provide effective mask-ventilation is life-saving One-handed face mask technique two-handed technique
32 LMA (laryngeal mask airway) LMA-C(CLASSIC) LMA-Flexible LMA- Proseal LMA- FASTRACH LMA `C` TRACH LMA c TRACH
33 Combitube The Combitube is a double lumen tube with esophageal obturator lumen and tracheal lumen. The proximal (large) oropharyngeal balloon serves to seal off the mouth and nose, The distal balloon (cuff) seals either (oesophagus or trachea) Oesophagus (95%), trachea (5%).
34 Trans tracheal Jet Ventilation (TTJV) Oxygen injected under high pressure (10-50 PSI) directly into the trachea. This is done by inserting a 14 gauge IV catheter or similar device through the cricothyroid membrane intermittent bursts of oxygen through this catheter
35 Cricothyrotomy Surgical airway Incision through crico - thyroid Membrane.
36 Tracheostomy Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea
37
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