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Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
Review of the New ASA Guidelines
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Review of the New ASA Guidelines

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I built this presentation using an outline of pre-existing and out-dated material (provided by Carin Hagberg, MD). I conducted both guided and independent literature research and contributed original …

I built this presentation using an outline of pre-existing and out-dated material (provided by Carin Hagberg, MD). I conducted both guided and independent literature research and contributed original content (approved by Dr. Hagberg) in addition to designing and creating the slides/media/graphics that compose this lecture in its entirety, as represented here.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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  • 1. 1 Review of the New ASA Guidelines Management of the Difficult Airway CARIN A. HAGBERG, MD JOSEPH C. GABEL PROFESSOR & CHAIR ∣ DEPT. OF ANESTHESIOLOGY THE UNIVERSITY OF TEXAS MEDICAL SCHOOL AT HOUSTON MEDICAL DIRECTOR ∣ PERIOPERATIVE SERVICES MEMORIAL HERMANN HOSPITAL, HOUSTON, TX
  • 2. RESEARCH GRANTS UNPAID CONSULTANT Karl Storz Endoscopy King Systems Ambu Ambu
  • 3. 3 “Sentinel Events” Associated w/ Anesthesia No. of Claims Permanent Brain Damage 867 Airway Injury 581 Difficult Intubation 466 Spinal Cord Injury 417 Medication Errors 283 Aspiration 213 Central Venous Catheter Injury 183 ASA Closed Claims N=8954; 1970-2007 J. Metzner et al; Best Practice & Research Clinical Anesthesiology; 25(2011) 263-76.
  • 4. 4 Closed Claims’ Analysis Best Practice & Research Clinical Anaesthesiology Julia Metzner MD, et al ‣ Esophageal intubation has nearly dissapeared. ‣ Inadequate oxygenation or ventilation has declined in OR setting, not OOR. ‣ Difficult intubation remains a concern 27% of adverse respiratory events. ‣ Pulmonary aspiration - 3rd most common respiratory event. J. Metzner et al; Best Practice & Research Clinical Anesthesiology; 25(2011) 263-76.
  • 5. 5 Practice Guidelines Management of the Difficult Airway An Updated Report by the ASA Task Force ‣ Systematically developed recommendations that assist the practitioner in making decisions ‣ Purpose to facilitate management of the DA & reduce the likelihood of adverse outcomes ‣ Not intended as standards of care or absolute requirements ‣ Revised & updated the 1993 and 2003 publication of ASA’s guidelines for management of the DA Anesthesiology 2013 118:251-70
  • 6. International Airway Algorithms Canada (Canadian Society of Anesthesiologists) Italy (SIARRTI) Germany (German Society of Anesthesiologists) Hungary (Hungarian Society of Anesthesiologists) UK (Difficult Airway Society)
  • 7. 7 Neck Circumference 100 Patients - BMI >40 kg/m2 Elective surgery PreOperative Measurements - TMD, SMD Height, Weight Neck circumference Mouth opening Aim to identify factors that complicate DL & intubation Intubation Difficulties Neither absolute obesity nor BMI Large neck circumference & high Mallampati scores Brodsky JB et al; Morbid Obesity & Tracheal Intubation. Anesth Analg 2002; 94:732-6
  • 8. 8 Patient History Airway history should be conducted on all patients, if feasible. Intent is to detect medical, surgical, & anesthetic factors that may indicate DA. Examine previous medical record, if available, in a timely manner. Anesthesiology 2013 118:251-70
  • 9. ESSENTIAL ROUTINE PREOPERATIVE AIRWAY EVALUATION • • Length of upper incisors • Voluntary: protrusion of mandibular teeth anterior to maxillary teeth - lip bite test • • • • Interincisor distance <4 cm ! Involuntary: maxillary teeth anterior to mandibular teeth Oropharyngeal class ( 3 or 4) Narrowness of palate Mandibular space compliance Anesthesiology 2013; 118:251-70
  • 10. ESSENTIAL ROUTINE PREOPERATIVE AIRWAY EVALUATION TMD <6 cm • Mandibular space length • Length of neck • Head/Neck ROM • Thickness of neck ? >40 cm ! Anesthesiology 2013; 118:251-70 SMD <12 cm
  • 11. Approach to the Difficult Airway Difficult Laryngoscopy & Intubation: LEMON LAW Look externally Evaluate 3-3-2 Mallampati Obstruction Neck mobility Hung, Orlando, Murphy, Michael; Management of the Difficult and Failed Airway, 2011
  • 12. Pediatric Airway Assessment Difficult Pediatric Airway: MOWS Mask fit - craniofacial abnormalities Obstruction - extrathoracic airway Wheezing - obstructive lung dz Spine - stiff/immobilized Brent R. King MD, FACEP, FAAEM, FAAP Professor of Emergency Medicine and Pediatrics Chair, Department of Emergency Medicine
  • 13. 13 Does the airway exam predict difficult intubation? Identify patients w/ individual predictors Determine any combinations of predictors that may lead to difficulty Perform additional testing & obtain preop consultation Review w/ expert(s) to formulate plan for airway management Ability to better accurately predict should reduce number of adverse outcomes & improve safety of airway management Ghatge J & Hagberg C. In Fleisher L (ed). Evidence-Based Practice of Anesthesiology. Elsevier 2013 104-18
  • 14. 14 Neck Circumference 100 Patients - BMI >40 kg/m2 Elective surgery PreOperative Measurements - TMD, SMD Height, Weight Neck circumference Mouth opening Aim to identify factors that complicate DL & intubation Intubation Difficulties Neither absolute obesity nor BMI Large neck circumference & high Mallampati scores Brodsky JB et al; Morbid Obesity & Tracheal Intubation. Anesth Analg 2002; 94:732-6
  • 15. VISCERAL ADIPOSITY Shearer ES; Obesity anaesthesia; the dangers of being an apple. Br J of Anesth 2013; 110 (2):172-4
  • 16. 16 Difficult Airway Algorithm Anesthesiology 2013 118:251-70
  • 17. 17 Basic Management Problems Anesthesiology 2013 118:251-70
  • 18. Basic Management Problems Difficulty with patient cooperation or consent Difficult mask ventilation Difficult supraglottic airway placement Difficult laryngoscopy Difficult intubation Difficult surgical airway access Anesthesiology 2013 118:251-70
  • 19. Basic Management Problems Difficulty with patient cooperation or consent Difficult mask ventilation Difficult supraglottic airway placement Difficult laryngoscopy Difficult intubation Difficult surgical airway access Anesthesiology 2013 118:251-70
  • 20. 20 Prediction of Difficult Mask Ventilation ‣ Prospective study - 1,502 pts - French university hospital ‣ DMV: inability to maintain O2 sat >92% or prevent/reverse signs of inadequate ventilation during PPMV under GA ‣ Incidence 5% Langeron O et al; Anesthesiology 2009; 92:1229-36
  • 21. 21 Difficult Mask Ventilation Pre-Operative Risk Factors M ask seal O besity; BMI >26 kg/m2 A ge >55 yrs N o teeth S noring >2 risk factors markedly increases risk Langeron O, et al. Anesthesiology 2000; 92:1229-36
  • 22. 22 Prediction & Outcomes: Impossible Mask Ventilation Review of 50,000 Anesthetics 53,041 BMV attempts (2004-08) ! 77 Impossible BMV (0.15%) Inability to exchange air during BMV, despite multiple providers, airway adjustments, or NMB Independent Predictors: MOANS II M ask seal O pening mouth (III or IV) A dult male N eck radiation S noring >3 risk factors markedly increase risk for IMV Sachin K, MD, MBA et al. Anesthesiology 2009; 110
  • 23. 23 Impossible Mask Ventilation 4x Difficult Intubation Sachin K, MD, MBA et al. Anesthesiology 2009; 110
  • 24. 24 Optimal Attempt at BMV 2 person effort Large oropharyngeal and/or nasopharyngeal airways Triple Airway Maneuver - Tilt head Advance mandible Mouth open
  • 25. 25 RAMP Helps maximize upper airway patency Nissen IPAD Improves ventilation mechanics Troop Elevation Pillow Lengthens apneic time period to critical hypoxia in massive obesity
  • 26. Basic Management Problems Difficulty with patient cooperation or consent Difficult mask ventilation Difficult supraglottic airway placement Difficult laryngoscopy Difficult intubation Difficult surgical airway access Anesthesiology 2013 118:251-70
  • 27. 27 Techniques for Difficult Ventilation ‣ Intratracheal ‣ Invasive jet stylet airway access ‣ SGA ‣ Oral and nasopharyngeal airways ‣ Rigid ventilating bronchoscope ‣ Two-person mask ventilation Anesthesiology 2013 118:251-70
  • 28. 28 Difficult SGA Placement ! SGA placement requires multiple attempts, in the presence or absense of tracheal pathology ! Incidence ? Anesthesiology 2013 118:251-70
  • 29. 29 Difficult SGA Placement In addition to routine airway evaluation tests, whether the LMA can be correctly placed and provide adequate ventilation should be evaluated before inducing GA • Angle between the oral and pharyngeal axes <90° • Severely limited mouth opening • Oropharyngeal pathology ! ! Takenaka I et al. Is awake intubation necessary when the LMA is feasible? Anesth & Analg 2000; 91:246-7
  • 30. Difficult SGA Placement Difficult SGA placement: RODS Restricted mouth opening Obstruction of upper airway (at or below larynx) Distortion/Disruption Stiff lungs/Spine Hung, Orlando, Murphy, Michael; Management of the Difficult and Failed Airway, 2011
  • 31. Basic Management Problems Difficulty with patient cooperation or consent Difficult mask ventilation Difficult supraglottic airway placement Difficult laryngoscopy Difficult intubation Difficult surgical airway access Anesthesiology 2013 118:251-70
  • 32. 32 Difficult Laryngoscopy It is not possible to visualize any portion of the VC after multiple attempts at conventional laryngoscopy ! Incidence 1.5-3% Anesthesiology 2013 118:251-70
  • 33. COOK MODIFICATION CORMACK-LEHANE CLASSIFICATION easy Predicts easy intubation in 95% of cases ! grade 1 ! ! restricted Likely to require gum elastic bougie, butgrade other no 2b adjuncts <3% need any intubation adjuncts grade 2a grade 3a Cook TM; Anesthesia 2000; 55:274-9 difficult Associated w/ difficult intubation in 75% of cases grade 3b ! Specialist intubation techniques are likely required grade 4
  • 34. 34 Difficult Tracheal Intubation Tracheal intubation requires multiple attempts, in the presence or absence of tracheal pathology ! Incidence 1.2-3.8% Anesthesiology 2013 118:251-70
  • 35. 35 Techniques for Difficult Intubation ‣ Awake ‣ Blind intubation intubation (oral/nasal) ‣ Fiberoptic intubation ‣ Intubating stylet-tube changer ‣ SGA as an intubation conduit ‣ Laryngoscope and shape ‣ Light blades of vaying design wand ‣ Videolaryngoscope Anesthesiology 2013 118:251-70
  • 36. Basic Management Problems Difficulty with patient cooperation or consent Difficult mask ventilation Difficult supraglottic airway placement Difficult laryngoscopy Difficult intubation Difficult surgical airway access Anesthesiology 2013 118:251-70
  • 37. Difficult Surgical Airway Difficult Cricothyrotomy: SHORT S urgery/disrupted airway H ematoma or infection O bese/access problem R adiation T umor Hung, Orlando, Murphy, Michael; Management of the Difficult and Failed Airway, 2011
  • 38. 38 Difficult Surgical Airway x
  • 39. 39 Alveolar Oxygen Delivery Actively pursue opportunites to deliver supplemental oxygen throughout the process of difficult airway management. Anesthesiology 2003; 98:1269-77
  • 40. 40 Basic Management Choices Anesthesiology 2013 118:251-70
  • 41. 41 Basic Management Choices Awake Intubation vs Non-Invasive Technique! Initial Intubation Approach vs Intubation Attempts After! GA Induction Invasive Technique! Initial Intubation Approach Video-Assisted Laryngoscopy! Initial Intubation Approach Spontaneous Ventilation! Preservation vs Spontaneous Ventilation! Ablation Anesthesiology 2013 118:251-70
  • 42. 42 Awake Intubation Anesthesiology 2013 118:251-70
  • 43. 43 Awake Intubation Awake Intubation ! Invasive Airway Access
 (b) Non-Invasive Intubation SUCCEED Cancel Case FAIL Consider feasibility of Other Options (a) Invasive Airway Access
 (b) ! Anesthesiology 2013; 118:251-70
  • 44. 44 Awake Intubation: Revisions LMA → SGA Anesthesia (LMA, ILMA, LT) All will work as ventilatory mechanisms All can be inserted blindly Few complications w/their use
  • 45. 45 Awake Intubation: Revisions Invasive Airway Access Surgical or percutaneous airway Jet ventilation, retrograde intubation added     May be performed via a catheter (cric or AEC) or via a bronchoscope (rigid or flexible)         Technique varies with type of procedure Vigilance is of the essence     ! Techniques inc classic, silk, gu (≥ 70 cm), and Safe, effective when techniqu Useful whenev limitations obsc opening (patho upper airway tr CAN VENTILATE Enk oxygen flow modulator Anesthesiology 2013; 118:251-70
  • 46. 46 Indications for Awake Intubation ‣ Previous DI ‣ Anticipated DA 𝘈 Prominent protruding teeth Small mouth opening Narrow mandible Micrognathia Macroglossia Short muscular neck Very long neck Limited neck ROM Congenital airway anomalies Obesity Pathology involving airway Malignancy involving airway Upper airway obstruction Benumof & Hagberg’s Airway Management, 3rd Edition; 2012.
  • 47. 47 Indications for Awake Intubation ‣ Trauma: - Face - Upper airway - Cervical spine ‣ Anticipated difficult BMV ‣ Severe risk of aspiration ‣ Respiratory failure ‣ Severe hemodynamic instability Artime CA, Sanchez A.  Preparation of the patient for awake intubation.  In: CA Hagberg (ed) Benumof and Hagberg’s Airway Management 3rd ediiton.  Elsevier, St. Louis, pp. 244, 2012
  • 48. 48 Intubation after Induction of GA Anesthesiology 2013 118:251-70
  • 49. 49 Intubation after Induction of GA Intubation Attempts After GA Initial Intubation Attempts SUCCEED FAIL From this point onwards consider: 1. Calling for help 2. Returning to spontaneous ventilation 3. Awakening the patient Anesthesiology 2013 118:251-70
  • 50. 50 Face Mask Ventilation - Adequate Alternative DI approaches include (not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (LMA, ILMA) as an intubation conduit (w/ or w/out fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation. Anesthesiology 2013 118:251-70
  • 51. 51 Intubation Attempts After GA Initial Intubation Attempts SUCCEED FAIL Face Mask Ventilation Adequate Face Mask Ventilation Inadequate Consider/Attempt LMA Adequate NON-EMERGENCY PATHWAY Inadequate EMERGENCY PATHWAY Anesthesiology 2013 118:251-70
  • 52. 52 Intubation Attempts After GA Initial Intubation Attempts SUCCEED FAIL Face Mask Ventilation Adequate Face Mask Ventilation Inadequate Consider/Attempt SGA Adequate NON-EMERGENCY PATHWAY Inadequate EMERGENCY PATHWAY ! Anesthesiology 2013; 118:251-70
  • 53. 53 Patient Anesthetized Intubation Unsuccessful Face Mask Ventilation ADEQUATE Alternative Approaches to Intubation SUCCEED Invasive Airway Access FAIL After Multiple Attempts Consider Feasibility of Other Options Awaken Patient ! Anesthesiology 2013; 118:251-70
  • 54. 54 Non-Emergency Pathway: Revisions ‣ LMA → SGA Anesthesia - LMA, ILMA ‣ Video-Assisted Laryngoscopy ! Anesthesiology 2013; 118:251-70
  • 55. 55 Face Mask Ventilation - NOT Adequate Anesthesiology 2013 118:251-70
  • 56. 56 Patient Anesthetized 
 Intubation Unsuccessful Face Mask Ventilation NOT Adequate Consider/Attempt SGA SGA NOT Adequate SGA Adequate ! Anesthesiology 2013; 118:251-70
  • 57. 57 Emergency Pathway Ventilation Inadequate Intubation Unsuccessful CALL FOR HELP Emergency, Non-Invasive Airway Ventilation (e) SUCCEED Invasive Consider Feasibility of Airway Access Other Options (a) (b)* FAIL Awaken Patient (d) Emergency Invasive Airway Access (b)* ! Anesthesiology 2013; 118:251-70
  • 58. Beware the inexperienced, ambitious clinician, who offers to help.
  • 59. 59 Emergency Non-Invasive Airway Ventilation Revisions ‣ SGA - ETC not mentioned ‣ Rigid Bronchoscope - Removed ‣ Retrograde & Jet ventilation - Now considered “invasive” Anesthesiology 2013 118:251-70
  • 60. 60 Airway Obstruction NON-PATHOLOGICAL ‣ Natural Anatomy - Tongue ‣ Supralaryngeal ventilatory mechanism - LMA, etc - Other alternative SGA PATHOLOGICAL ‣ Abnormal Anatomy - Cancer - Hematoma - Abscess - Edema ‣ Subglottic ventilatory mechanism - Rigid bronch, TTJV - Surgical airway
  • 61. 61 Surgical Technique First Choice Laryngeal/tracheal disruption Upper airway abscess or obstruction Combined mandibular maxillary fractures
  • 62. 62 Suggested Contents Portable Storage Difficult Airway Management ‣ Contents - Alternative rigid laryngoscope blades - Videolaryngoscope - Tracheal tubes of various sizes - Tracheal tube guides - SGAs - Flexible fiberoptic scope - Equipment suitable for emergency invasive airway access - An exhaled carbon dioxide detector - Retrograde intubation equipment removed ! Anesthesiology 2013; 118:251-70
  • 63. 63 Most Common Devices in Practice Difficult Airway Management ‣ Devices - Conventional laryngoscope blades - Glidescope with stylet - SGAs (ILMA & Disposable LMA) - Flexible fiberoptic scope ! Anesthesiology 2013; 118:251-70
  • 64. 64 Extubation ASA Task Force Recommendations ‣ Consider relative merits of awake vs. deep extubation ‣ Evaluate factors that may interfere w/upper airway patency ‣ Formulate a plan for immediate reintubation if the airway becomes compromised ‣ Consider a jet stylet ! Anesthesiology 2013; 118:251-70
  • 65. Extubation Difficult Extubation: SOAP ME S uction O xygen A irway - BMV, masks not just ETTs P harmacology M onitoring E quipment Hilary Klonin
  • 66. 66 Communication of the DA Lorraine Foley, MD,Tufts Medical School
  • 67. 67 Communication of the DA
  • 68. 68 ASA Difficult Airway Algorithm Take Home Messages ‣ Anticipate the possibility of DA management by performance of a thorough pre-op airway assessment ‣ Secure the airway awake if difficulty is suspected ‣ Have a back-up plan(s) if the initial plan to secure the airway fails
  • 69. 69 Experience Matters Good decisions come from experience, unfortunately, experience often comes from bad decisions.
  • 70. 70
  • 71. 71 Summary ‣ Algorithms only serve as guidelines ‣ Become educated ‣ Equipment must be available ‣ Practice, practice, practice!! ‣ Do what works BEST for you ‣ You CAN make a difference!!
  • 72. 17th Annual Society Airway Management Scientific Meeting Philadelphia PA September 20-22, 2013

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