Difficult Intubation &Difficult Airway Trolley Rashid M Khan Sr. Consultant National Trauma Centre Muscat, Sultanate of Oman
Objectives of this talk• Introduction to the difficult airway for the nurse assistants.• How to assess, manage & assist with difficult airway!• The algorithm and its purpose!• The difficult airway trolley!• Understanding of different airway devices!
Airway management is really easy… …except when it isn’t…
To Maximize Success……recognize and predict difficult airway…choose appropriate technique and equipment…possess technical skills to assist intubation, drugs, and devices
The anesthesia nurses role!• Should Predict the difficult airway!• Provide assistance & support!• Has equipment/drugs ready!• Has experience to offer!
Predicting the Difficult Airway…if you have time
LEMON LawLook at patient’s head & neck anatomyExamine the airwayMallampatiObstructionsNeck mobility
Look at Head & Neck Anatomy• Obesity: rapid desaturation, difficult intubation, ventilation• Facial hair: hides small chin, can make bagging difficult / impossible• Large teeth: hide airway, obscure tube passage• Jagged teeth: lacerate balloon
Always start with Pre-oxygenation • Provides oxygen reservoir within lungs, blood and body tissues. • Allows for several minutes of apnea without desaturation. • Nitrogen washout. • Use NRB, BVM or NIV for 3-5 mins.
Helping Preoxygenation andmask ventilation prior to intubation• Keep appropriate size oral airway or nasal trumpet ready.• Leave dentures.• In bearded patients, apply water-soluble lubricant or opsite to get good seal, especially if lots of facial hair
Apneic Oxygenation• New Concept!• Involves maintaining Nasal Prongs patent upper airway passage & oxygenation during apneic period.• Use Nasal prongs @ 15l 02.
Always start intubation attempts:• After a good preoxygenation.• Using technique with which you are most experienced and comfortable.• Don’t repeat the same technique more than twice, you will not get a different result.
Endotracheal intubation Basic instruments that you should keepready Magill’s Forceps Laryngoscope Styleted ETT
Role of the nurse anesthetist during laryngoscopic attempts:• Providing adequately checked laryngoscope & ETT.• Providing cricoid pressure, if full stomach.• Applying BURP maneuver to facilitate laryngeal visualization.• Inflating the cuff and ETT fixation after ascertaining correct tracheal intubation.
LMA Take-Home Points for Nurses • Always test cuff before use • Don’t lubricate anterior mask • Insert only in comatose patient • Keep cuff inflated until patient awake • Don’t throw out!! Used 40 – 50 times
2. Combitube®• Seals oropharyngeal and nasopharyngeal cavities• Ventilate through blue port – Good breath sounds and no air in stomach continue ventilating – No breath sounds and air in stomach use white tube
Indications of LMA, Combitube• Routine / emergency procedures• Known / unknown difficult airway• During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible
Contraindications of LMA, Combitube …has limited mouth opening …has not fasted, except in emergency …has lung compliance …is not profoundly unconscious …has oropharyngeal growth, trauma
Always keep AlternativeIntubation Aids at Easy & Known Locations
4. Flexible Fiberoptic Scope Advantages • Allows direct airway visualization • Causes little hemodynamic stress • Nasotracheal or orotracheal route • Can be done in all age groups • Requires minimal neck movement
4. Flexible Fiberoptic Scope Disadvantages• Expensive• Expertise requires practice• Delicate equipment needs careful maintenance• Visual field easily impaired by blood and secretions