DIFFICULT AIRWAY MANAGMENT Dr.N.SANTHOSH KUMAR MD ANESTHESIA (2 nd Yr)
AIRWAY MANAGEMENT AND MAINTAINING OXYGENATION ARE THE FUNDAMENTAL RESPONSIBILITIES OF ANY BASIC DOCTOR. TO MANAGE A DIFFICULT AIRWAY, WE HAVE TO FIRST UNDERSTAND WHAT IS MEANT BY A DIFFICULT AIRWAY
DIFFICULT MASK VENTILATION NOT POSSIBLE FOR THE ANESTHESIOLOGIST TO PROVIDE ADEQUATE FACE MASK VENTILATION TO MAINTAIN SATURATION >90%. DIFFICULT INTUBATION NOT BEING ABLE TO VISUALIZE ANY PORTION OF THE VOCAL CORDS AFTER >3 ATTEMPTS AT CONVENTIONAL LARYNGOSCOPY TRACHEAL INTUBATION REQUIRES >3 ATTEMPTS TAKES >10 MINUTES FAILED INTUBATION INABILITY TO PLACE THE ETT AFTER >3 INTUBATION ATTEMPTS OR TAKES >10 MINUTES
Outcomes of difficult intubation.
PREVALENCE Even with proper evaluation only 15 to 50 % of difficult airway were picked up While difficult face mask ventilation in general is about 1:10,000 out of which again 15% proved to be difficult intubation While incidence of extreme difficult or abandon intubation in general surgery patients are 1:2000 but in obstetrics it is 1:300
DIFFICULT AIRWAY Anticipated Unanticipate d 6
DIFFICULT AIRWAY ANTICIPATED DIFFICULT AIRWAY ELECTIVE EMERGENCY
MANAGEMENT PLAN OF ANTICIPATED DIFFICULT AIRWAY 2016-1-19 8 8
MANAGEMENT PLAN OF ANTICIPATED DIFFICULT AIRWAY 1. DISCUSSION WITH COLLEAGUES IN ADVANCE. 2. EQUIPMENT TESTED BEFORE. 3. SENIOR HELP BACKUP. 4. DEFINITE INITIAL PLAN (A) FOR VENTILATION AND INTUBATION. 5. DEFINITE PLAN (B) THAN OPTION OF AWAKE INTUBATION. 6. SURGERY TEAM STANDBY. 9
Pre oxygenation: How Much Is Enough? Two techniques common in use: 1. Tidal volume breathing (TVB) of oxygen for 3 5 min 2. 5 Deep breaths (DB) Both are equally effective in increasing arterial oxygen tension (Pao 2 ). 10
Consider the merits and feasibility Awake Intubation vs IIntubation after induction of GA Non Invasive technique vs IInvasive technique for initial approach for initial approach Preservation of spontaneous vs Ablation of spontaneous Ventilation ventilation 11 11
MANAGEMENT PLAN OF UNANTICIPATED DIFFICULT AIRWAY 2016-1-19 12 12
UN ANTICIPATED DIFFICULT AIRWAY PROBLEMS UNEXPECTED ENCOUNTER WITH DIFFICULT AIRWAY IS MOSTLY GONE WORSE BECAUSE MAINLY GA IS ALREADY GIVEN INCLUDING (NMB,S). EQUIPMENT MAY NOT BE IN HAND. SENIOR AND BACK UP PLAN NOT AVAILABLE SO DELAY OCCUR IN ACTIVE RESUSCITATION BACKUP AIRWAY MANAGEMENT PLANS MAY BE POORLY THOUGHT OUT 13
Difficult airway CAN T INTUBATE CAN T VENTILATE or CAN T INTUBATE AND CAN T VENTILATE (CVCI) 14
Techniques for Difficult Airway Management TECHNIQUES FOR DIFFICULT VENTILATION TWO PERSON MASK VENTILATION SUPRAGLOTTIC AIRWAYS; ORAL AND NASOPHARYNGEAL AIRWAYS ESOPHAGEAL TRACHEAL COMBITUBE LARYNGEAL MASK AIRWAY SUBGLOTTIC INVASIVE AIRWAYS; INVASIVE AIRWAY ACCESS TRANSTRACHEAL JET VENTILATION 15 15
Techniques for Difficult Intubation Optimal external laryngeal manipulation Alternative laryngoscope blades Intubating stylet or tube changer Laryngeal mask airway as an intubating conduit Light wand (maximum of 2 attempts?) Alternative technique of intubation Awake intubation Blind intubation (oral or nasal) Fiberoptic intubation Retrograde intubation Invasive airway access 16
Failed first attempts Ventilate with 100% oxygen Monitor vital signs Maintain depth of anaesthesia Re evaluate head position Administer anti cholinergic if not already given Call for help early before the situation deteriorates Keep track of time. BURP maneuver (Backwards Upwards Rightwards Pressure on Thyroid Cart.) If you decide to make a second attempt, don't use the identical technique Re evaluate laryngoscopy technique change blade Try using a smaller endotracheal tube Use of gum elastic bougie if epiglottis seen Use of LMA /ILMA Use an intubation aid such as a stylet or light wand
ORAL AND NASOPHAEYNGEAL AIRWAYS 18
Rigid laryngoscope blades of Macintosh alternate design and size Mc Coy Magill Miller Polio 19
Bullard rigid fiberoptic laryngoscope 20 20
Fibreoptic bronchoscope Universal cord Body Insertion cord 21
Stylette Devices Endotracheal Tube Introducer Lighted Stylette 22
GUM ELASTIC BOUGIE (GEB) First used in England Cheap Good in patients in whom only epiglottis is visualized 23 23
Supraglottic Airways 1.Combitube 2. Laryngeal Mask Airway (LMA ) and Intubating LMA (ILMA) 24 24
The Esophagealtracheal Combitube Useful as emergency airway Two lumens allow function whether place in esophagus or trachea Esophageal balloon minimizes aspiration 25 25
Laryngeal Mask Airway 26
VARIANTS OF LMA LMA classic (standard) LMA flexiable (reinforced) LMA unique (disposable LMA) LMA Fastrach (intubating LMA) LMA Proseal (gastric LMA) 2016-1-19 27 27
LMA Fastrach (intubating LMA) Rigid, anatomically curved, airway tube that is wide enough to accept an 8.0 mm cuffed ETT and is short enough to ensure passage of the ETT cuff beyond the vocal cords Rigid handle to facilitate onehanded insertion, removal Epiglottic elevating bar in the mask aperture which elevates the epiglottis as the ETT is passed through Available in three sizes, one size for children, two sizes for adults 28 28
LMA C Trach Ventilation Visualization Intubation 29 29
LMA Proseal High seal pressure up to 30 cm H 2 0 Providing a tighter seal against the glottic opening with no increase in mucosal pressure Provides more airway security Enables use of PPV in those cases where it may be required A built in drain tube designed to channel fluid away and permit gastric access for patients with GERD 30 30
Awake Intubation 31
RETROGRADE INTUBATION
TFE catheter: prevent the ET tube form redundancy over the guidewire decrease trauma, increase success rate 34
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What are we going to do if we can t intubate? Plans A, B and C Know this answer before you tube. 38
Plan A : (ALTERNATE) DIFFERENT LENGTH OF BLADE DIFFERENT TYPE OF BLADE DIFFERENT POSITION 39
Plan B : (BVM and BLIND INTUBATION Techniques ) CAN YOU VENTILATE WITH A BVM? (CONSIDER TWO PERSON MASK VENTILATION) COMBI TUBE? LMA AN OPTION? 40
What do we do when faced with a Can t Intubate Can t Ventilate situation? PLAN C : NEEDLE, SURGICAL 41
INVASIVE ACCESS Cricothyrotomy Tracheostomy 42
DIFFICULT AIRWAY MANAGEMENT: Can t Intubate, can t ventilate Surgical Airway Tracheostomy too slow Cricothyroidotomy quick 43
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FAILURE WHY DOES IT HAPPENS? NO CRITICAL DISCUSSION WITH COLLEAGUES ABOUT PROPOSED MANAGEMENT PLAN NO REQUEST FOR EXPERIENCED HELP EXAGGERATED IDEA OF PERSONAL ABILITY ILL CONCEIVED PLAN A AND/OR PLAN B POORLY EXECUTED PLAN A AND/OR PLAN B PERSISTING WITH PLAN A TOO LONG, STARTING THE RESCUE PLAN TOO LATE NOT INVOLVING, AND PREPARING, SURGICAL COLLEAGUES 46 46
DIFFICULT AIRWAY ASA DIFFICULT AIRWAY ALGORITHM RECOGNIZED UNRECOGNIZED LMA PROPER PREPARATION GENERAL ANESTHESIA +/- PARALYSIS MASK VENTILATION EMERGENCY PATHWAY NO COMBITUBE TTJV AWAKE INTUBATION CHOICES SUCCEED FAIL SURGICAL AIRWAY REGIONAL ANESTHESIA CANCEL CASE YES NON -EMERGENCY PATHWAY INTUBATION CHOICES * AWAKEN INTUBATION CHOICES SURGICAL AIRWAY * REGROUP SUCCEED FAIL CONFIRM * Intubation choices include use of different laryngoscope blades, LMA as an intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation. AWAKEN ANESTHESIA WITH MASK VENTILATION SURGICAL AIRWAY EXTUBATE OVER JET STYLET 2016-1-19 47 47
ASA ALGORHYTHM 48