Difficult airway management- our experience J. Starkopf, A. Sell, A. Sõrmus, J. Samarütel Clinic of Anaesthesiology and Intensive Care Tartu University Clinics Estonia
Clinic of Anaesthesiology and Intensive Care Tartu University Clinics 8 departments 29 operating theatres 50 intensive care beds 60 anaesthesiologists 167 nurses
Number of Anaesthesias 25 000 20 000 15 000 18 926 1 446 3 358 0 19 596 20 718 3 214 1 455 2 912 882 727 379 10 000 5 000 0 11 424 10 953 10 733 3 268 3 759 4 296 2001 2002 2003 I/v Mask LMA Endotr. Regional
Definition of DA Difficult airway is defined as the clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with face mask ventilation, difficulty with tracheal intubations, or both Anaesthesiology 2003;98:1269-1277
Definition of DA Difficult airway (DA) is defined as the clinical situation in which a trained anaesthesiologist can not intubate the patient using standard intubation techniques
Difficult airway protocol Raskelt intubeeritava haige protokoll üldanestesioloogia osakonnas Jrk No Perekonnanimi Eesnimi Kuupäev Vanus Pikkus Kaal Hgl. Diagnoos Operatsioon Mallampati skoor Suu avamine cm Türeomentaalne distants cm (mõõtmisel pea maksimaalselt kukla Sternomentaalne distants cm (mõõtmisel pea maksimaalselt kukla Pea liikuvus Gormack, Lehane'i klassifikatsioon (hinnang larüngoskoopial) 1- Eeldatud 2- Mitte-eeldatud raske intubatsioon 1- Suu kaudu FOI 2- Nina kaudu FOI 1- Ärkvel FOI 2- Narkoosis FOI Anestesioloogid Rö-graphia CT Fotod Märkused ( larüngoskoop, int.toru, juh varras, kõrimask, eelnev FOI, väike lõu etteulatuvad ülahambad, muu anat. p klass 1- kurgukaared, pehme suulagi, uvula on nähtavad klass 2- kurgukaared, pehme suulagi on nähtavad, uvula on kaetud keelepära poolt klass3-ainult kõva suulagi on nähtav alla 90 kraadi, = 90 kraadi, üle 90 kraadi 1-häälepaelad nähtavad 2-häälepaelte tagumine osa nähtav 3-häälepaelu ei näe 4-epiglottist ei näe
Anticipated difficult airway I class II class III class Mallanpati 1985
Equipment and organisation Set of devices McCoy laryngoscope Oxford endotracheal tubes Bougie LMA Intubating LMA Cricotomy set Combitube
Equipment and organisation Set of devices Bronhoscopy 4 experienced colleagues McCoy laryngoscope Oxford endotracheal tubes Bougie Cricotomy set Combitube Jet ventilation 2 experienced colleagues
Material Retrospective analysis of anaesthesia records and difficult airway protocols
Material Retrospective analysis of anaesthesia records and difficult airway protocols 3 year period- 2000-2002 No of endotracheal anaesthesias- 21 445 (total No of anaesthesias- 35 990) 86 cases of difficult airway Frequency of occurrence 1 : 249 (0.4%)
86 cases of difficult airway Mean age- 47 yr. (16-81 yr.) Male - 49, female 37 patients Fiberoptic intubation was used in 58 cases
Causes of the difficult airway in 86 cases Anatomical variations, congenital disorders, diseases No of patients Frequency 45 52% Acute infections 21 24% Trauma to face and neck 11 13% Tumours 9 10%
Bedside tests (n = 26) Medium Range Inter-incisior gap Thyromental distance Sternomental distance 3 cm 0.5 5 cm 6.5 cm 1.5 10.5 cm 12 cm 4 20 cm
Bedside tests (n = 37) Neck extension Frequency > 90 0 76 % < 90 0 24 %
BURP- Back Up Right Pressure
McCoy laryngoscope
Teatis. Patsient Jänes Juta (52 a) viibis 30.juunil 2004.a. Tartus Naistekliinikus operatsioonil. Operatsioon teostati üldnarkoosis, mille jaoks oli vajalik viia hingetorusse spetsiaalne toru operatsiooniaegseks kunstlikuks ventilatsiooniks. Selle toru sisseviimine tavapäraselt oli võimatu patsiendi anatoomiliste iseärasuste tõttu ja kasutati spetsiaalset instrumenti fiiberbronhoskoopi.. Operatsioon ja narkoos möödusid probleemideta. Edaspidi, kui tekib vajadus mingiks operatsiooniks, on oluline informeerida arste (narkoosiarste, kirurge) selles probleemist. Lugupidamisega Dr. Andres Sell, SA TÜK T K Anestesioloogia ja Intensiivravi Kliiniku üldanestesioloogia osakonna juhataja Tel.7 318 322 30.06.04
Conclusion Successful management of DA intails Constant readiness in department- DA cart and A few specially trained colleagues who could assure effective use of these tools
Difficult airway how we are prepared? Knowledge Experience and skills Equipment Organisation
Knowledge Literature International meetings Teaching Visits to other hospitals Standardized documentation Retrospective analysis of data
Experience and skills Number of anaesthesias Anesthesia methods Endotracheal Mask, laryngeal mask Thoracic surgery ENT surgery Bronchoscopy Jet-ventilation Tracheostomy