ASA Guideline Review

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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......

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 ASA Guideline Review 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. 2 RESEARCH GRANTS Karl Storz Endoscopy King Systems Ambu SPEAKERS’ BUREAU LMA North America Ambu A/S Cook EQUIPMENT Aircraft Medical Ambu A/S Clarus Medical Cook Cookgas Intersurgical Karl Storz Endoscopy King Systems LMA North America Mercury Medical Verathon UNPAID CONSULTANT Ambu
  • 3. 3 Lecture Objectives ‣ Review specifics of revised ASA DA guidelines ‣ Review basics of a preoperative airway exam ‣ Discuss appropriate options for CVCI situation ‣ Discuss appropriate options for extubation of the difficult airway ‣ Communication of DA to future caregivers
  • 4. 4 Difficult Airway The clinical situation in which a conventionally trained anesthesiologist experiences difficulty with FMV of the upper airway, tracheal intubation, or both. Represents a complex interaction between patient factors, the clinical setting, and the skills of the practitioner.
  • 5. 5
  • 6. 6 APSF Survey Results Identify Safety Issues Priority Airway - Still #1 Difficult Airway Management 72 Cost-Saving: Production Pressure 62 Anesthesia Delivery: Remote Sites 61 Anesthesia Delivery: Office-Based 58 Neurologic Deficit Due to Anes Touch 58 56 Coronary Heart Disease (pts) Occupational Stress Fatigue 55 53 Medication Errors 52 Cost-Saving Time for Pre-Op Eval 52 Stoelting, RK: APSF Newsletter 1999; 14:6
  • 7. 7 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 2003 98:1269-77
  • 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 MR, if available in a timely manner.
  • 9. ESSENTIAL ROUTINE PREOPERATIVE AIRWAY EVALUATION TMD <6 cm 1) Length of upper incisors! 2) Involuntary: maxillary teeth anterior to mandibular teeth! 3) Voluntary: protrusion of mandibular teeth anterior to maxillary teeth - lip bite test ! ? >40 cm 4) Interincisor distance <4 cm! 5) Oropharyngeal class (MP 3 or 4)! 6) Narrowness of palate! 7) Mandibular space compliance ! Anesthesiology 2013; 118:251-70 SMD <12 8) Mandibular space length! 9) Length of neck! 10) Head/Neck ROM! 11) Thickness of neck
  • 10. 10 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 acurately predict should reduce number of adverse outcomes & improve safety of airway management In Fleisher L (ed). Evidence-Based Practice of Anesthesiology. W.B. Saunders, 2004; 34-46
  • 11. 11 Neck Circumference 100 Patients - BMI >40 kg/m2 Elective surgery PreOperative Measurements - TMD, SMD Height, Weight Neck circumference Aim to identify factors that complicate DL & intubation Intubation Difficulties Neither absolute obesity nor BMI Large neck circumference & high Mallampati scores Brodsky JB, Lemmens HJM, Brock-Utne JG, Vierra M, Saidman LI; Morbid Obesity & Tracheal Intubation. Anesth Analg; 2002; 94:732-6.
  • 12. 13 Other options include (not limited to): surgery utilizing face mask or SGA anesthesia (LMA, ILMA, laryngeal tube), local anesthesia infiltration or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore, these options may be of limited value if this step in the algorithm has been reached via the Emergency Pathway. Invasive airway access includes surgical or percutaneous airway, jet ventilation, & retrograde intubation. Alternative DI approaches include (not limited to): videoassisted 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. Consider re-preparation of the patient for awake intubation or canceling surgery. Emergency non-invasive airway ventilation consists of a SGA. Anesthesiology 2013 118:251-70.
  • 13. 14 Face Mask Ventilation Not Adequate Consider/Attempt SGA SGA NOT Adequate SGA Adequate EMERGENCY AIRWAY PATHWAY Call for Help Emergency, Non-Invasive Airway Ventilation ! Anesthesiology 2013; 118:251-70
  • 14. 15 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, MD, PhD, Masso E, MD, Huraux C, MD, Guggiari M, Bianchi A, MD, Coriat, MD, Riou B, MD, PhD Anesthesiology 2009; 92:1229-36
  • 15. 16 Difficult Mask Ventilation Pre-Operative Risk Factors M: mask seal O: BMI >26 kg/m2 A: Age >55 yrs N: Lack of teeth S: History of snoring >2 risk factors markedly increases risk Langeron O, MD et al. Anesthesiology 2000; 92:1229-36
  • 16. 17 Techniques for Difficult Intubation ‣ Esophageal tracheal combitube ‣ Intratracheal jet stylet ‣ Invasive airway access ‣ Laryngeal mask airway ‣ Oral & nasopharyngeal airways ‣ Rigid ventilating bronchoscope ‣ Transtracheal jet ventilation ‣ Two-person mask ventilation
  • 17. 18 Optimal Attempt at BMV 2 person effort Large oropharyngeal and/or nasopharyngeal airways Triple Airway Maneuver - T: tilt head A: advance mandible M: mouth open
  • 18. 19 Alveolar Oxygen Delivery Actively pursue opportunites to deliver supplemental oxygen throughout the process of difficult airway management. Anesthesiology 2003; 98:1269-77
  • 19. 20 Difficult Laryngoscopy It is not possible to visualize any portion of the VC after multiple attempts at conventional laryngoscopy ! Incidence 1.5-3%
  • 20. 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
  • 21. 22 R.A.M.P. Helps maximize upper airway patency Nissen IPAD Improves ventilation mechanics Troop Elevation Pillow Lengthens apneic time period to critical hypoxia in massive obesity
  • 22. 23 Difficult Tracheal Intubation Tracheal intubation requires multiple attempts, in the presence or absence of tracheal pathology ! Incidence 1.2-3.8%
  • 23. 24 Sniffing Position Oral Axis (OA), Paryngeal Axis (PA) & Laryngeal Axis (LA) must be aligned to facilitate viewing of glottis by DI
  • 24. 25 Techniques for Difficult Intubation ‣ Alternative laryngoscope blades ‣ Awake intubation ‣ Blind intubation (oral/nasal) ‣ Fiberoptic intubation ‣ Intubating stylet-tube changer ‣ Invasive airway access ‣ Light wand ‣ Retrograde intubation ‣ Video Laryngoscopy
  • 25. x
  • 26. 27 Difficult Airway Algorithm Consider the relative merits & feasibility of 3 basic management choices: Intubation Attempts After! GA Induction Awake Intubation vs Non-Invasive Technique! Initial Intubation Approach vs Invasive Technique! Initial Intubation Approach Spontaneous Ventilation! Preservation vs Spontaneous Ventilation! Ablation Video-Assisted Laryngoscopy! Initial Intubation Approach ! Anesthesiology 2003; 98:1269-77
  • 27. 28 Difficult Airway Algorithm Develop primary & alternative strategies Awake Intubation Airway Secured Surgical Access Airway Approached Non-Surgical SUCCEED Cancel Case FAIL Consider feasibility of Other Options Surgical Airway ! Anesthesiology 2013; 118:251-70
  • 28. 30 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
  • 29. 31 Non-Emergency Pathway Patient Anesthetized, Intubation Unsuccessful Mask Ventilation Adequate Alternative Approaches to Intubation FAIL After Multiple Attempts SUCCEED Invasive Airway Access Consider Feasibility of Other Options Awaken Patient ! Anesthesiology 2013; 118:251-70
  • 30. 32 Alternative Approaches to Intubation Fail After Multiple Attempts ‣ Invasive airway access includes: - Surgical or percutaneous tracheostomy or cricothyrotomy ‣ Other options include (not limited to): - Surgery utilizing face mask or LMA anesthesia - LA infiltration - Regional nerve block ‣ Consider re-preparation of the patient for awake intubation or canceling surgery
  • 31. 33 Difficult Airway Recognized DA difficult airway RA regional anesthesia GA general anesthesia TI tracheal intubation Surgery Can Be Done Under RA surgery cannot be quickly terminated surgery can be quickly terminated all patient positions access to airway not important good airway access patient agrees to awake TI if RA fails RA acceptable RA acceptable RA FAILS cancel case awake TI ! GA poor airway access RA unacceptable RA FAILS ASA DA Algorithm cooperative noncooperative patient patient redo RA awake TI GA In Benumof JL(ed): Airway Management Principles & Practice. St.Louis, Mosby-Year Book,1996,150. GA Plan B ready to go
  • 32. 34 Beware the inexperienced, ambitious clinician, who offers to help
  • 33. 35 Emergency Pathway ! Ventilation Inadequate Intubation Unsuccessful ONE MORE CALL FOR HELP INTUBATION ATTEMPT Emergency, Non-Invasive Airway Ventilation Invasive Airway Access (b)* SUCCEED Consider Feasibility of Other Options (a) Options for emergency, non-invasive airway ventilation include (not limited to): rigid bronchoscope, Combitube,TTJ, LMA ventilation FAIL Awaken Patient Emergency, Invasive (d) Airway Access (b)* ! Anesthesiology 2013; 118:251-70
  • 34. 36 LMA & Combitube Both will likely work as ventilatory mechanisms Both can be inserted blindly Few complications w/their use Combitube often unfamiliar & unavailable Proseal & other SGA’s Consideration of intubation conduit
  • 35. 37 Airway Obstruction NON-PATHOLOGICAL ‣ Natural Anatomy - Tongue ‣ Supralaryngeal ventilatory mechanism - LMA, etc - Other alternative SLA PATHOLOGICAL ‣ Abnormal Anatomy - Cancer - Hematoma - Abscess - Edema ‣ Subglottic ventilatory mechanism - Rigid bronch, TTJV - Surgical airway
  • 36. 38 Rigid Bronchoscopy Able to ventilate below obstruction Inexperienced Risk of trauma to posterior wall of trachea Often unavailable
  • 37. 39 FF Preparation time Visualization of tube passage Success rate of intubation Mechanical strength Endoscopic orientation Integrated suction channel Retromolar route Nasal route Mobile light source (battery, adapter) curve Learning Costs (acquisition, repair) RBI Longer No High Lower Poorer Yes No Yes Available Flatter Higher Shorter Yes High Higher Better No Yes No Available Steeper Lower Comparison of Flexible Fiberscope & Rigid Bronchoscope ! Rudolph C, et al; Minerva Anestesiol 2007; 73:567-74
  • 38. 40 Retrograde Intubation       Techniques include classic, silk, guide wire (≥ 70 cm), and FOB ‣ Techniques: classic, silk, guide wire, & Safe, effective and fast when technique is familiar FOB Useful whenever anatomic limitations obscure glottic opening (pathology, CSI, upper airway trauma) ‣ Safe, effective, & fast when technique is familiar   CAN VENTILATE situations ‣ Useful whenever anatomic limitations obscure glottic opening (pathology, CSI, upper airway trauma) ‣ CAN VENTILATE situations
  • 39. flexible)   Technique varies with type of procedure Transtracheal   Vigilance is of the essence Jet Ventilation   ‣ May be performed via catheter Enkor AEC) or via bronchoscope (cric oxygen flow modulator (rigid or flexible)   OPEN THE AIRWAY !!!! ‣ Techniques vary with type of procedure ‣ Vigilance is of the essence   May be performed via a catheter (cric or AEC) or via a bronchoscope (rigid ‣ OPEN THE AIRWAY!!! or flexible)     Technique varies with type of procedure Vigilance is of the essence 41
  • 40. 42 Transtracheal Jet Ventilation ‣ Often unavailable ‣ Used inappropriately ‣ Significant risk of barotrauma - Too large TV - Too short exhalation phase - Catheter dislodgement
  • 41. 43
  • 42. 44
  • 43. 45 Cricothyrotomy Final CVCI Option Site Inferior CTM curved blunt dilator tracheal hook trousseau tracheal dilator Methods Needle Percutaneous Surgical Equipment Scalpel Tube Finger
  • 44. 46
  • 45. 47
  • 46. 48 Surgical Technique First Choice Laryngeal/tracheal disruption Upper airway abscess or obstruction Combined mandibular maxillary fractures
  • 47. 49 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 2003; 98:1269-77
  • 48. 50 Standard Approaches Awake extubation Anesthetized (deep) extubation Extubating after positive “cuff leak test” Extubating when expert help is available
  • 49. 51 Important Considerations Setting & Circumstances Surgical Procedure Type of anesthetic Cardiorespiratory stability Underlying patient disease Establishment of present airway
  • 50. 52 Lorraine Foley, MD, Tufts Medical School
  • 51. 53 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
  • 52. 54 Experience Matters.
  • 53. 55
  • 54. 56 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!!