Difficult Airway Victor M. Gomez, M.D. Pulmonary Critical Care Medicine Medical City Dallas Hospital
Difficult Airway Definition Predicting a difficult airway Preparing for a difficult airway Extubation and ETT exchange Conclusions
Definition It is a situation where an experienced endoscopist encounters difficulty providing face mask ventilation, difficulty intubating or both If both = FAILED AIRWAY
Predicting a Difficult Airway Difficult bag-mask ventilation expected? Difficult laryngoscopy expected? Difficult endotracheal tube placement expected? Difficult surgical airway management predicted?
Predicting Difficulties with Bag-Mask Ventilation Surgery Hematoma Obstruction Radiation Trauma or Tumors Bearded Obese Noo teeth Elderly Snorer
Predicting a Difficult Laryngoscopy Prominent mandibular or maxillary incisors Lack of jaw mobility Hard palate shape Neck length/thickness/mobility Compliance of submandibular space Visibility of the uvula and retropharyngeal structures or Mallanpati score
Predicting a difficult ETT placement or advancement Difficult laryngoscopy Unable to visualize or recognize vocal cords Neck tumors or large hematomas compressing the airway
Predicting a difficult surgical airway Difficult anatomy Lack of equipment Contraindications: infection, coagulopathy, neck hardware Preparing for it after everything has failed
Preparing for a Difficult Airway Teamwork: respiratory therapist, nurses, physicians, surgeons Formulate a plan: Know the difficult airway algorithm Knowledge and availability of alternative airway management techniques and equipment
Preparing for a Difficult Airway Is this a crash airway? Patient preparation: Cooperation, positioning, IV access, stabilization Aids during conventional laryngoscopy Alternative airway management ASK FOR HELP
Aides During Laryngoscopy Positioning Sedation, paralysis and topical anesthesia Bougie Alternative laryngoscope blade View Max, Truview, Flipper
Endotracheal Tube Introducer (Bougie) The top of bougie passes just beneath the epiglottis. Vibrations, or clicks, can be palpated as the soft tip of the bougie passes against the rigid DRG tracheal rings.
Truview
Rusch View Max Allows visualization of the vocal cords in the most difficult cases Functions like a traditional laryngoscope Provides a patented lens system which provides a more anterior view of the larynx than a standard laryngoscope DRG
Max View
Flipper Laryngoscope blade The Flipper is a unique fiber optic laryngoscope blade that can give that extra bit of anterior exposure sometimes needed during difficult intubations. Articulating tip design allows the end of the blade to be raised by squeezing a lever next to the handle. One-handed operation produces a more complete exposure of the glottis, making intubation easier. DRG
Alternatives to Laryngoscopy LMA (Fastrach) or Combitube Trachlight or Light wand Blind nasal intubation Fiber optic bronchoscopy Retrograde intubation Surgical airway: Cricothyrotomy Needle or tube
Trachlight
Trachlight Based upon the principle of transillumination of the soft tissues of the neck, the Trachlight device facilitates intubation even in the most challenging patients. DRG
LMA Sizes 4, 5, 6 DRG
Combitube
Retrograde Intubation
Williams Airway An oralpharyngeal airway A means of intubating the trachea A guide for fiber optic broncoscopy placement Sizes 9 & 10 DRG
Aintree Intubation Catheter
Transtracheal Jet Ventilator / Needle Trach DRG
Cricothyrotomy Kit
Emergency Cricothyrotomy Kit
Melker Cook Quick Trach Used for emergency airway access when endotracheal intubation cannot be performed. Airway access is achieved DRG
CO2 Detector DRG
Extubation and ETT Exchange Avoid accidental and self extubations Use of Aintree or tube exchangers Ultimately may need a surgical airway
Cook Tube Exchanger 1 An AEC introducer (COOK) is introduced through the lumen of the existing tracheal tube after airway evaluation (laryngoscopy) Dr AREZKI Farid SERVICE D'ANESTHESIE REANIMATION CH SARREGUEMINES. FRANCE DRG
Cook Tube Exchanger 2 The tracheal tube removed Dr AREZKI Farid SERVICE D'ANESTHESIE REANIMATION CH SARREGUEMINES. FRANCE DRG
Cook Tube Exchanger 3 The new tracheostomy tube is inserted over the exchange catheter, with the distal, supraglottic cuff inflated (10 ml of air). Dr AREZKI Farid SERVICE D'ANESTHESIE REANIMATION CH SARREGUEMINES. FRANCE DRG
Conclusions Difficult airways are uncommon but not rare Frequently leads to serious adverse outcomes Planning and preparation always improve chances for better outcome
Conclusions Knowledge and frequent use of different techniques and equipment are essential You must learn to do your own tricks
DRG
V1 Difficult Airway Algorithm. Anesthesiology, V 98, No 5, May 2003
Slide 64 V1 Victor, 10/24/2009
Difficult Airway Algorithm. Anesthesiology, V 98, No 5, May 2003
Parker directional Flex-it stylet DRG