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ASA Guideline Review: Management of the Difficult Airway

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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. 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. 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 ❦
  • 3. 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. ❦
  • 4.
  • 5. 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 Coronary Heart Disease (pts) Occupational Stress Fatigue 56 55 53 Medication Errors ❦ 52 Cost-Saving Time for Pre-Op Eval 52 Stoelting RK: APSF Newsletter 1999; 14:6
  • 6. 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 publication of ASA’s guidelines for management of the DA. Anesthesiology 2003 98:1269-77 ❦
  • 7. 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. ❦
  • 8. 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 2003 98:1269-77 SMD <12 8) Mandibular space length! 9) Length of neck! 10) Head/Neck ROM! 11) Thickness of neck
  • 9. Identify patients w/ individual predictors! Does the airway exam predict difficult intubation? ❦ 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
  • 10. Neck Circumference ! Aim to identify factors that complicate DL & intubation! 100 Patients! BMI >40, elective surgery! PreOperative Measurements:! TMD, SMD! height, weight! neck circumference, mouth opening! 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.
  • 11. Other Options (not limited to)! ✤ ✤ ✤ surgery (face mask, LMA anesthesia)! local anesthesia infiltration! regional nerve block! Invasive Airway Access! Surgical or Percutaneous Tracheostomy or Cricothyrotomy! Alternative, Non-Invasive Approaches-DI (not limited to)! ✤ ✤ ✤ ✤ ✤ ✤ ✤ ✤ different laryngoscope blades! LMA-intubating conduit (FOB optional)! FOB! intubating stylet or tube exchanger! light wand! retrograde intubation! blind oral intubation! blind nasal intubation! Consider re-preparation of the patient for awake intubation or canceling surgery! Emergency, Non-Invasive Airway Ventilation (not limited to)! ✤ ✤ ✤ rigid bronchoscope! esophageal-tracheal combitube ventilation! transtracheal jet ventilation
  • 12. 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 difficult intubation approaches include (not limited to) video-assisted laryngoscopy, alternative laryngoscope blades, SGA (LMA, IL MA), as an intubation conduit (w/or w/out fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, 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
  • 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 difficult intubation approaches include (not limited to) video-assisted laryngoscopy, alternative laryngoscope blades, SGA (LMA, IL MA), as an intubation conduit (w/or w/out fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, 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
  • 14. 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! Reported incidence of DMV 5%! ❦ Langeron O, et al; Anesthesiology 2000; 92:1229-36
  • 15. Difficult Mask Ventilation PreOperative Risk Factors M: mask seal ! O: BMI >26 kg/m2 ! A: age >55 yrs ! N: lack of teeth ! S: history of ❦ Langeron O, et al; Prediction of Difficult Mask Ventilation. Anesthesiology 2000; 92:1229-36
  • 16. Techniques for Difficult Ventilation ✤ Esophageal tracheal combitube! ✤ Intratracheal jet stylet! ✤ Laryngeal mask airway! ✤ Oral & nasopharyngeal airways! ✤ Rigid ventilating bronchoscope! ✤ Invasive airway access! ✤ Transtracheal jet ventilation! ✤ Two-person mask ventilation ❦
  • 17. Optimal Attempt at BMV ! 2 person effort! Triple airway maneuver:! T: tilt head! A: advance mandible! M: mouth open! Large oropharyngeal and/or nasopharyngeal airways! ❦
  • 18. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management ❦ Anesthesiology 2003; 98:1269-77
  • 19. 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 restricted Predicts easy intubation in 95% of cases! ! grade 1 ! <3% need any intubation adjuncts grade 2a Likely to require grade 2b gum elastic bougie, but no other adjuncts 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. TROOP ELEVATION PILLOW ✤ Helps maximize upper airway laryngoscopy position. “HELP” Head-elevated patency! Rich J. Anesth Analg 2004; 98(1):364-5 ✤ ✤ ❦ Improves mechanics of ventilation! NISSEN IPAD Lengthens apneic time period to critical hypoxia in massive obesity
  • 22. Difficult Tracheal Intubation Tracheal intubation requires multiple attempts, in the presence or absence of tracheal pathology! Incidence 1.2-3.8%! ❦
  • 23. Sniffing Position OA PA LA DL ❦ Oral Axis (OA), Paryngeal Axis (PA) & Laryngeal Axis (LA) must be aligned to facilitate viewing of glottis by DI
  • 24. ! Alternative laryngoscope blades! Awake intubation! Techniques for Difficult Intubation Blind intubation (oral/nasal)! Fiberoptic intubation! Intubating stylet-tube changer! Light wand! Retrograde intubation! Invasive airway access!
  • 25. x
  • 26. Difficult Airway Algorithm Consider the relative merits & feasibility! of 3 basic management choices: Intubation Attempts After! GA Induction Awake Intubation Non-Invasive Technique! Initial Intubation Approach vs Invasive Technique! Initial Intubation Approach Spontaneous Ventilation! Preservation ❦ vs vs Spontaneous Ventilation! Ablation ASA Task Force on Management of the Difficult Airway.! Anesthesiology 2003; 98:1269-77
  • 27. Difficult Airway Algorithm Video-assisted laryngoscopy as an initial approach to intubation! ❦ ASA Task Force on Management of the Difficult Airway.! Anesthesiology 2003; 98:1269-77
  • 28. Difficult Airway Algorithm Develop primary & alternative strategies! Awake Intubation Airway Approached! Non-Surgical SUCCEED Cancel Case ❦ ASA Task Force on Management of the DA.! Anesthesiology 2003; 98:1269-77 Airway Secured! Surgical Access FAIL Consider Feasibility of! Other Options Surgical Airway
  • 29. Intubation Attempt After GA Initial Intubation Attempts SUCCESSFUL UNSUCCESSFUL Face Mask ! Ventilation! Adequate Face Mask Ventilation Inadequate Consider/Attempt LMA Adequate ❦ Anesthesiology 2013; 118:251-70 NON-EMERGENCY! PATHWAY Inadequate EMERGENCY PATHWAY
  • 30. Non-Emergency Pathway Patient Anesthetized, Intubation Unsuccessful! Mask Ventilation Adequate Alternative Approaches to Intubation SUCCEED Invasive Airway Access ❦ Anesthesiology 2013; 118:251-70 FAIL! After Multiple Attempts Consider Feasibility of! Other Options Awaken Patient
  • 31. Invasive airway access includes:! ✤ Surgical or percutaneous trachesotomy or cricothyrotomy! Alternative Approaches to Intubation Fail After Multiple Attempts Other options include (not limited to)! ✤ Surgery utilizing face mask or LMA anesthesia! ✤ LA infiltration! ✤ Regional nerve block! Consider re-preparation of the other patient for awake intubation or canceling surgery! ❦
  • 32. DIFFICULT AIRWAY (DA) RECOGNIZED DA=Difficult Airway Surgery Can Be Done Under Regional Anesthesia (RA) GA=General Anesthesia Surgery Can Be Quickly Terminated All Patient Positions (access to airway not important) RA=Regional Anesthesia TI=Tracheal Intubation Surgery Cannot Be Quickly Terminated Good Access to Airway, Patient Agrees to Awake TI if RA Fails RA Acceptable Poor Access to Airway RA Unacceptable RA Acceptable RA Fails RA Fails Cancel Case Awake TI GA Redo RA Patient Remains Cooperative ASA DA Algorithm Patient is Not Cooperative Awake TI GA GA with Plan B Ready to Go In Benumof JL (ed): Airway Management Principles and Practice. St. Louis, Mosby-Year Book, 1996, 150.
  • 33. ❦ Beware of the inexperienced, ambitious clinician, who offers to help.
  • 34. Emergency Pathway ❦ Options for emergency, non-invasive airway ventilation include (not limited to): rigid bronchoscope, Combitube, TTJ, LMA ventilation
  • 35. 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
  • 36. 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
  • 37. Rigid Bronchoscopy! Able to ventilate below obstruction! Inexperienced! Risk of trauma to posterior wall of trachea! Often unavailable
  • 38. Comparison of Flexible Fiberscope & Rigid Bronchoscope FF RBI Longer Shorter No Yes Success rate of intubation High High Mechanical strength Lower Higher Endoscopic orientation Poorer Better Integrated suction channel Yes No Retromolar route No Yes Nasal route Yes No Available Available Flatter Steeper Higher Lower Preparation time Visualization of tube passage Mobile light source (battery, adapter) curve Learning Costs (acquisition, repair) ❦ Rudolph C, et al; Minerva Anestesiol 2007; 73:567-74
  • 39. Retrograde Intubation
 Ø Techniques include classic, silk , guide wire, and FOB! ! Ø Safe, effective and fast when technique is familiar ! ! Ø Useful whenever anatomic limitations obscure glottic opening (pathology, CSI, upper airway trauma)! ! Ø CAN VENTILATE situations
  • 40. Transtracheal Jet Ventilation Ø May be performed via a catheter (cric or AEC) or via a bronchoscope (rigid or flexible)! ! Ø Technique varies with type of procedure! ! Ø Vigilance is of the essence! ! Ø OPEN THE AIRWAY !!!!
  • 41. Often unavailable! Transtracheal Jet Ventilation Used innappropriately! Significant risk of barotrauma! ✤ Too large TV! ✤ Too short exhalation phase! ✤ Catheter dislodgement! !
  • 42. Cricothyrotomy Ø Trousseau tracheal dilator Life-saving technique that should be mastered! Methods include needle, percutaneous, and surgical! Ø Tracheal hook Ø Ø Curved blunt dilator Final CVCI option in ALL airway algorithms! Universal cricothyrotomy catheter set! Cuffed airway catheter and instrumentation for both wire-guided and surgical techniques
  • 43. Surgical Technique First Choice Laryngeal/tracheal disruption! Upper airway abscess or obstruction! Combined mandibular maxillary fractures
  • 44. Consider relative merits of awake vs. deep extubation! Extubation & ASA Task Force Recommendations 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
  • 45. Standard Approaches ✤ ✤ ✤ ✤ Awake extubation! Anesthetized (deep) extubation! Extubating after positive “cuff leak test”! Extubating when expert help is available
  • 46. Important Considerations Setting & Circumstances! Surgical Procedure! Type of anesthetic! Cardiorespiratory stability! Underlying patient disease! Establishment of present airway ❦
  • 47. ❦ Lorraine Foley, MD, Tufts Medical School
  • 48. 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
  • 49. Experience Matters.
  • 50. Take Home Points Algorithms serve only as guidelines! Equipment must be available! Become educated! Practice, practice, practice!!! Do what works BEST for you! You can make a difference!!