How to Predict and Avoid Airway Disasters Muhammad Umer Ihsan
Four Key Aspect of Assessing a Difficult Airway Difficult Bag Mask Ventilation Difficult Direct Laryngoscopy Difficult Extra-glottic devices Difficult Cricothyrotomy
Difficult Bag Mask Ventilation MOANS Mask Seal Obstruction/Obesity Age No Teeth Stiff lungs
Difficult Bag Mask Ventilation MOANS Mask Seal Facial hair mustache or beard Disrupted anatomy- trauma, Chronic, Acute
Acute Disrupted Anatomy
Chronic Disrupted Anatomy
Difficult Bag Mask Ventilation MOANS Obstruction/Obesity Increasing incidence of elevated BMI Utility in epiglottitis remains
Obstruction/Obesity
Difficult Bag Mask Ventilation MOANS Age >55 Reduced upper airway elasticity
Difficult Bag Mask Ventilation MOANS No Teeth Helpful for visualization But loss of seal for the mask
Difficult Bag Mask Ventilation MOANS Stuff Lungs or neck Consider nasopharyngeal airways and oral airway
Difficult Direct Laryngoscopy LEMON Look Externally Evaluate 3-3-2 Mallampati Obstruction/Obesity Neck Mobility
Difficult Direct Laryngoscopy LEMON Look Externally- at first glimpse Gestalt Gut feeling First impression
Difficult Direct Laryngoscopy LEMON Evaluate 3-3-2 Inter incisor distance of three fingers Mental hyoid distance-3 fingers Hyoid-thyroid distance-2 fingers
Difficult Direct Laryngoscopy LEMON Mallampati Sitting up Head in sniffing position Open mouth, extrude tongue
Difficult Direct Laryngoscopy LEMON Obstruction/Obesity
Difficult Direct Laryngoscopy LEMON Neck Mobility
Difficult Extra glottic Devices RODS Restricted Mouth Opening Obstruction Distorted Anatomy Stiff lungs or C-spine
Difficult Cricothyrotomy SHORT Surgery or disrupted airway Hematoma (or infection or abscess) Obesity/Obstruction Radiation Tumor
Predicting the Difficult Four key aspects of assessing airway difficulty Difficult Bag Mask Ventilation-MOANS Difficult Direct Laryngoscopy-LEMON Difficult Extra-glottic device RODS Difficult Cricothyrotomy-SHORT
1. Preparation 2. Preoxygenation 3. Pretreatment ( not routinely done) 4. Paralysis with induction 5. Positioning 6. Placement with proof 7. Postintubation Management 7 Ps of Intubation
Pearl for the patient with increased BMI Preparation is the key. Equipment- nasopharyngeal airways an oral airway. Reverse Trendelenburg gravity helps you Build up occiput and prepare to perform external Laryngeal manipulation ELM, Expect desaturation. Have intubating stylet handy - Bougie. Cook catheter
Clinical Decisions Does this patient require intubation? Is this a difficult intubation? LEMON. MOANS. RODS. SHORT? Do I have time? Crash intubation required? Should paralytic: be used? Is this a difficult intubation? LEMON. MOANS. RODS. SHORT?
ELM External Laryngeal manipulation Backwards Upward Right Pressure BURP maneuver Primary operator dependent Does not replace cricoid pressure/sellick s maneuver Improve 1 Grade
Who desaturates Non rebreather apparatus delivers FiO2 that approaches 70%. Encourage patient to take Vital Capacity breaths (or 3 minutes or 8 full breaths for nitrogen washout) Bag - Mask - Seal can deliver up to 98% FiO2, no need to bag the patient.
Who Desaturates Extremes of ages Pediatric patients Elderly patients Patients with co-morbidities- CHF,COPD, DM, Chronic illness Pregnant patients Morbidly obese patients
Intubating Stylets Keep it handy Inability to pass an ETT visualization of cords or only epiglottis viewed If stylet passes greater than 30 cm without resistance you are in the esophagus. Seldinger two person technique Maintaining laryngoscope in place during' passage of ETT facilitates passage Multiple uses - confirmation of intubation, LMA or Surgical airway use.
Pearls for the patient with angioedema Preparation is the key Equipment- nasopharyngeal airways. Jelly Lignocaine Experts - anesthesia. ENT Naso pharyngoscope, intubating bronchoscope Have surgical airway kit at the bedside
Questions