Difficult airway assessment and management by sardar saud abbas
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Brief description on how to assess airway and manage difficult intubation. There is alot of detail about airway management but this will get you through
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Difficult airway assessment and management by sardar saud abbas
- 1. Difficult Airway Assessment and Management DR SARDAR SAUD ABBAS DA (HMC), 2ND YEAR RESIDENT (KTH)
- 2. Contents ▪ Definition ▪ Causes ▪ Assessment or predictor of Difficult airway ▪ Plan A, Plan B, Plan C For Anticipated Difficult Airway ▪ ASA Difficult Airway Algorithm ▪ Tools at our disposal
- 3. Definition Difficult to ventilate ▪ When sign of inadequate ventilation could not be reversed by mask ventilation or oxygen saturation could not be maintained above 90%. Provided that the pre- ventilation oxygen saturation level was within the normal range. Difficult to intubate ▪ If a trained anesthetist using conventional laryngoscope takes more than 3 attempts or more than 10 minutes are required to complete tracheal intubation.
- 4. Causes Anesthetist 1) Inadequate pre operative assessment 2) Inadequate equipment 3) Lack of experience 4) Poor Technique 5) Malfunctioning of equipment 6) Inexperience assistant Patient 1) Congenital causes 2) Acquired causes
- 5. Congenital 1)Down syndrome 2) Pierre Robin Syndrome (micrognathia, Macroglossia, Cleft soft palate) 3) Goldenhars Syndrome: (molar and mandibular hypoplasia) 4) Marfan Syndrome ETC Acquired 1) Arthritis 2) Tumor 3) Trauma 4) Obesity 5) Acute burns 6) Large Goiter 7) Radiotherapy ETC
- 6. Anatomical Factors affecting Laryngoscopy ▪ Short neck ▪ Protruding incisor teeth ▪ Long high arched palate ▪ Poor mobility of neck ▪ Large tongue (macroglossia) ▪ Enlarge soft tissue of the mouth, pharynx and larynx
- 7. Assessment or predictor of Difficult airway ▪ Atlanto-occipital movement ▪ Assessment of A.O extension ▪ Mandibular protrusion ▪ Assessment of mandibular space ▪ Inter incisor gap ▪ Sternomental Distance ▪ Upper lip bite test ▪ LEMON assessment
- 8. Atlanto-occipital movement ▪ Patient is asked to hold head erect, patient asked to extend the head maximally and the examiner estimates the angle traversed by the occlusal surface of the upper teeth ▪ Visual assessment or using goniometer Grade I > 35 degree Grade II 22-34 degree Grade III 12-21 degree Grade IV < 12 Degree
- 9. Assesment of A.O Extension ▪ Can also be done by asking the patient to look at the floor and at the wall after flexing and fixing the neck as shown
- 11. Assessment of mandibular space ▪ Can be examined as thyromental and hyomental space ▪ Thyromental distance : Measure upper edge of thyroid cartilage to chin. 7 cm approx. ▪ Hyomental Distance: Distance between mentum and hyoid bone Grade I > 6cm Grade II 4-6 cm Grade ii <4 cm
- 12. Inter incisor gap ▪ Inter-incisor distance with maximal mouth opening ▪ Normal value > 5cm / 3 fingers ▪ Significance < 3cm difficult laryngoscopy < 2cm difficult LMA insertion
- 13. Sternomental Distance ▪ Savva test ▪ Distance from the upper border of the manubrium to the tip of mentum, neck fully extended mouth closed ▪ Minimal acceptable value – 12.5 cm
- 14. Upper lip bite test
- 15. LEMON assessment ▪ Look externally ▪ Evaluate the 3-3-2 ▪ Mallampati ▪ Obstruction ▪ Neck mobility
- 16. Look Externally ▪ Obesity ▪ Short muscular neck ▪ Large breast ▪ Buck teeth ▪ Receding jaw ▪ Burns ▪ Facial trauma ▪ Stridor ▪ Macroglossia
- 17. Evaluate the 3-3-2 ▪ 3 fingers fit in mouth ▪ 3 finger fit from mentum to hyoid cartilage ▪ 2 finger fit from the floor of the mouth to the top of the thyroid cartilage
- 19. Obstruction ▪ Blood ▪ Vomitus ▪ Teeth ▪ Epiglottis ▪ Dentures ▪ Tumors ▪ Impaled objects
- 20. Neck mobility ▪ Previously discussed
- 21. Anticipated Difficult Intubation ▪ Discussion with colleagues in advance ▪ Equipment tested before ▪ Senior help back up ▪ Plan A – Ventilation and intubation ▪ Plan B – Awake intubation ▪ Plan C – CRIC needle, surgical (when you cant ventilate and intubate)
- 22. ASA Difficult Airway Algorithm
- 23. Tools at our disposal ▪ Rigid Laryngoscope blades of alternative desing ▪ Tracheal tube guides (stylet, EGB) ▪ Laryngeal mask airways ▪ Fiber optic ▪ Retrograde intubation equipment
- 25. Tracheal tube guides (stylet, EGB)
- 26. Laryngeal mask airways ▪ LMA – Classic ▪ LMA – Flexible ▪ LMA – Unique ▪ LMA – Fastrach ▪ LMA – Proseal
- 27. Fiber optic
- 28. Retrograde intubation equipment ▪ Advance 18 guage sheath needle ▪ Attach to a 5 cc syringe ▪ In a cephalad direction through the cricothyroid membrane into trachea ▪ Free flow of air confirm positioning ▪ Remove the needle and syringe leaving sheath in place
- 29. ▪ Advance the wire guide through sheath in cephalad direction until the tip of the wire guide can be retrieved through the mouth or nose ▪ Remove the sheath, leaving the wire guide in place
- 30. ▪ Advance the 11.0 French black TFE Catheter ante grade over the wire into the trachea until resistance is met at the cricothyroid membrane ▪ TFE catheter prevent ET tube form redundancy over the guide wire decrease trauma, increase success rate
- 31. ▪ TFE catheter in position, advance the ETT over catheter and wire guide below the level of the vocal cord.
- 32. ▪ Remove the wire guide and catheter. Advance ETT into correct position and inflate the balloon cuff.
- 33. Thank You