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Current Concepts: Difficult Airway Management


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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 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.

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Current Concepts: Difficult Airway Management

  2. 2. Sir Robert Reynolds Macintosh 3 ingredients of a good anesthetic... GOOD AIRWAY GOOD AIRWAY GOOD AIRWAY
  3. 3. Perhaps the most fundamental principle in all of anesthesiology
  4. 4. 5 Scope of the Problem Local: 25k GA’s performed - 250-75 possible unanticipated DA/DIs per yr National: 46k ASA members - 46k DIs per yr - Doesn’t consider other clinical settings/nonmember care providers International: HUGE problem In patients undergoing GA, 1-3% incidence of unanticipated DA
  5. 5. 6 Prospective Study All major airway events over a 1yr period Anesthesia, ICU, ED Important insights regarding airway management complications
  6. 6. 7 Case Types Elective ASA I-II, <60 Obese ENT Obstructive lesions Outcomes Deficiencies in airway assessment Underutilization of awake intubation Inappropriate use of SGA Poor planing Aspiration Most frequent cause of anesthesia-related mortality 56% SGA complications
  7. 7. 8 Extrinsic Factors: Clinician features commonly included judgement & training personal + institutional preparedness Increasing use of capnography is the single change with the greatest potential to prevent deaths Intrinsic Factors: Patient features contributed to >75% anesthetic events
  8. 8. INTEGRATION Mallampati score Neck circumference Thyromental distance Neck ROM Critical in deciding best approach
  9. 9. 10 Prediction of Difficult Tracheal Intubation Time for a Paradigm Change Langeron O, MD, PhD, Cuvillon P, MD, Ibanez-Esteve C, MD, Lenfant F, MD, PhD, Riou B, MD, PhD, LeManach Y, MD, PhD Anesthesiology 2012; 117:1123-33
  10. 10. 11 Gray Zone Important to assess risk of DI beyond a dichotomous approach Patients should be identified as low, intermediate, & high risk Implement an airway management strategy accordingly
  11. 11. 12 Difficult Airway
  12. 12. 13 i-CAT™ Award-Winning Cone Beam 3D Imaging System Endoscopy Ultrasound
  13. 13. 14 ASA Awake intubation: non-invasive (e.g. fiberoptics) vs. invasive access (e.g. cricothyroidotomy) Canada No recommendations France Awake technique (fiberoptic intubation, transtracheal oxygenation, retrograde intubation or tracheostomy) UK (DAS) Italy
 (SIAARTI) Germany (DGAI) No recommendations Awake intubation in severe cases (expert decision): fiberoptic or retrograde intubation; general anaesthesia in borderline cases Maintenance of spontaneous breathing, awake technique: (fiberoptic intubation, LMA, tracheostomy) Anticipated Difficult Airway Heidegger T, Gerig HJ. Best Pract Res Clin Anaesthesiol 2005; 19:661-741
  14. 14. 15 Indications for Awake Intubation ‣ Previous DI ‣ Anticipated DA𝘈 - 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 JL: Airway Management Principles & Practice. 1996; 9:161
  15. 15. 16 Indications for Awake Intubation ‣ Trauma: - Face - Upper airway - Cervical spine ‣ Anticipated difficult BMV ‣ Severe risk of aspiration ‣ Respiratory failure ‣ Severe hemodynamic instability Benumof JL: Airway Management Principles & Practice. 1996; 9:161
  16. 16. 17 Marco Brunori
  17. 17. 18 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.
  18. 18. 19 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
  19. 19. 20 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
  20. 20. 21 Prediction & Outcomes: Impossible Mask Ventilation Review of 50,000 Anesthetics 53,04 BMV attempts (2004-08) 77 Impossible BMV (0.15%) Inability to exchange air during BMV attempts, despite multiple providers, airway adjustments, or NMB Independent Predictors M: mask seal O: mouth opening (III or IV) A: adult male N: neck radiation S: history of snoring >3 risk factors markedly increase risk for IMV Sachin K, MD, MBA et al. Anesthesiology 2009; 110
  21. 21. 22 Impossible Mask Ventilation 4x Difficult Intubation
  22. 22. 23 Simpler method for CPR??
  23. 23. 24 Cardiac-only resuscitation & minimizing delays or interruptions in chest compressions increase survival ABC ! CAB Exception: infants/children where cardiorespiratory arrest is usually secondary to hypoxia Endotracheal intubation remains the gold standard for securing the airway Against the routine use of cricoid pressure as part of airway management Continous waveform capnography for confirmation of ETT placement
  24. 24. 25 Recommendations for Continuous Capnography ‣ All patients undergoing advanced life support ‣ Undergoing or recovering from moderate or deep sedation ‣ In all anesthetized patients, regardless of the airway device used ‣ All patients whose trachea is intubated, regardless of patient location May, 2011
  25. 25. 26 Failed laryngoscopy: 0.04-0.07% Marco Brunori
  26. 26. 27 Difficult laryngoscopy: 1.5-13% Marco Brunori
  27. 27. 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
  28. 28. In current anesthetic practice, there are a myriad of devices & techniques to ensure that the airway is patent.
  29. 29. 30 1988-1998 Decade of SGA Anesth Analg 2010;110:Cover
  30. 30. 31 2001-2011 Decade of Video Laryngoscopy Anesth Analg 2010;110:Cover
  31. 31. 32 Original Research Telemedicine & Telepresence for Prehospital & Remote Hospital Tracheal Intubation Using a GlideScope™ Videolaryngoscope: A Model for TeleIntubation Sakles JC, MD, FACEP, Mosler J, MD, Hadeed G, MPH, Hudson M, MD, Valenzuela T, MD, Latifi R, MD, FACS Telemedicine & e-Health, April 2011
  32. 32. ! ! ! Dr. Thomas M. Hemmerling from McGill University Health Centre has created the world’s first intubation robot, called the Kepler Intubation System (KIS), a robotic arm with a video laryngoscope that’s controlled via a joystick. ! ! Intubation bot lets doctors safely shove tubes down unconscious human throats By Michael Gorman, Apr 16th 2011
  33. 33. FIBEROPTIC LIGHTED STYLETS Shikani Optical Stylet 34 Air-Vu Levitan FPS Scope Pocket Scope Foley Airway Styler Video Airway System SHIKANI FAMILY
  34. 34. 35 Bonfils Intubation Fiberscope™ ‣ Rigid FOB stylet ‣ Fixed shape w/ 400 curve ‣ Movable eye-piece, adapter ‣ Battery or FOB light source ‣ Portable, rugged ‣ Retromolar or transmolar route - w/ and w/out laryngoscopy ‣ Adult & pedi sizes
  35. 35. 36 Hybrid Scopes Sensa Scope® - Rigid S-shaped endoscope - Stererable tip - Built-in camera & LED light source - Connects to a video monitor to all full screen image - Miniaturized CMOS chip allows for high image quality Video Rifl Scope™ - Rigid video styler - Articulating tip 1350 - Powered solely by lithium CR-123 batteries - LCD screen that rotates 1800 - Miniaturized CMOS chip allows for high image quality
  36. 36. 37 Olympus MAF™ Battery-driven fiber videoscope incorporating video camera, light source, & recording unit Still images & movies can be recorded to a memory chip Camera body can rotate either side by 900 LCD panel can tilt 0-1200 2.6 mm working chanel
  37. 37. 38 ® AMBU aSCOPE™ aSCOPE™ Sterile & single-use flexible fiberoptic scope - 5.3 mm (>6.0 ETT) 63 cm length New camera technology Lightweight, ergonomic handle Reusable screen, Ambu aScope™ monitor Always available, no cleaning & repairs, no cross contamination
  38. 38. 39 Flex Intubation Video Endoscope CMOS distal chip 5.5 mm (w) x 65 cm (l) (6.5 mm ETT) 2.3 mm working channel Deflection 1400 Integrated LED light source “Satin Sheath” requires no lubrication Highly portable w/ battery & AC Video & still images Compatible w/ C-MAC monitor & C-HUB
  39. 39. 40 5 Scope Nasal Intubation
  40. 40. 41 Difficult Mask Ventilation Can’t Intubate, Can’t Ventilate LMA, help, transtracheal catheterization, surgical ASA cricothyroidotomy 1 intubation attempt, LMA, Combitube, awakening, Canada transtracheal airway LMA, transtracheal catheterization, surgical France cricothyroidotomy Help, LMA, transtracheal catheterization, surgical UK (DAS) cricothyroidotomy Anesthesiology 2003; 98:1261-68 Can J Anaesth 1998; 45:757-76 Ann Fr Réanim 1996; 15:207-14 Anaesthesia 2004; 59:675-94 Oxygenation; LMA or Combitube; transtracheal Italy
 (SIAARTI) catheterization or surgical cricothyroidotomy Minerva Anestesiol 1998; 64:361-73 Oxygenation; LMA or Combitube; transtracheal Germany (DGAI) catheterization or surgical cricothyroidotomy Anaesth Intensiv 2004; 5:302-6 Heidegger T, Switz , Vergleich - unerwartet schwieriger Atemweg
  41. 41. 42 AHA Guidelines ! ! ERC/ITLS Guidelines
  42. 42. 43 EZ Tube LMA Supreme LTS-D i-Gel Air-Q Newer Generation SLA’s
  43. 43. 44 Gastro-LT™ Designed for obtaining & maintaining airway patency during procedures in which gastric access is desired Deep sedation or general anesthesia
  44. 44. 45
  45. 45. 46 Baska Mask Single-use, silicone cuffless device Built-in bite block Anterior strap to aid placement Two drain tubes (active suction, drainage)
  46. 46. 47 Tulip Single-use, PVC Similar to COPA Depth markings for depth insertion Green (small) Orange (medium) Red (large)
  47. 47. 48 Considerations Using SGA as Conduit for Intubation ‣ Type of device - Simple SGA vs Intubating SGA ‣ Difficult airway scenario - Predicted vs Unpredicted - Elective vs Emergent ‣ Technique - Awake vs Asleep - Blind +/- Bougie - FOB +/- Aintree exchange catheter ‣ Exchange or leave in place ‣ Equipment cost & availability
  48. 48. 49 Aintree Airway Exchange Catheter ‣ Polyethylene, 1cm markings ‣ 19 Fr, 56 cm, straight distal tip ‣ Hollow, allows FOB passage (4mm scope; distal 3mm free) ‣ 3 distal ports & luer-lock connector for jet ventilation ‣ Used for exchange of SGAs ‣ Limitations of LMA - Length, narrowness, aperture bars
  49. 49. POCKET Bougie™ ‣ 14 Fr (4.7 mm) solid intubation guide ‣ Balanced rigidity, flexibility, & memory w/ no metal core ‣ Double-sided depth markings ‣ Tactiglide technology ‣ Designed to fit into a pocket
  50. 50. 51 Difficult Airway Society Pediatric Difficult Airway Guidelines ‣ Target audience is non-specialists - Wish to learn or maintain pediatric airway skills - Rehearse unexpected difficult airway scenarios - Teach good practice ‣ Developed 3 separate algorithms, 1-8 yo - DMV after routine induction - Unanticipated DTI as above - CICV after paralysis ‣ Grade I evidence minimal
  51. 51. 52 Failure to manage the airway continues to be among the leading anesthesia-related causes of adverse outcomes in obstetrics
  52. 52. “Often we speak of the safety of modern anesthesiology; it is safe because of the committment to learn from previous errors, to discover new techniques & equipment, and to perform at the highest possible level each and every day”
  53. 53. History of Airway Techniques Gum Elastic Bougie 1949 Miller Blade 1941 FOB Intubation 1972 Retrograde Intubation 1960 Macintosh Blade 1943 First SGA 1981 TTJV 1971 Lighted Stylet 1958 Bullard 1989 Bonfils 1983 Cricothyrotomy comeback 1976 54 UpsherScope Glidescope 1996 2003 ASA DA DCI Video Sensascope 1993 2002 2007 WuScope 1994 ASA DA 2003 Shikani 1996 McGrath 2005
  54. 54. 55 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
  55. 55. 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 56
  56. 56. 57 Cricothyrotomy Final CVCI Option Site Inferior CTM curved blunt dilator tracheal hook trousseau tracheal dilator Methods Needle Percutaneous Surgical Equipment Scalpel Tube Finger
  57. 57. Cricothyrotomy may be necessary to secure the airway ! <50% of anesthesiologists felt competent to perform Difficult Airway Management: Practice Patterns Among Anesthesiologists Practicing in the United States Have We Made Any Progress? Ezri T, MD, Szmuk P, MD, Warters RD, MD, Katz J, MD, Hagberg C, MD
  58. 58. 59 ‣ Needle cric rescue technique of choice ! ‣ Often unsuccessful - Barotrauma - BD - Death ! ‣ Practitioner must be experienced. Institute early!!
  59. 59. 60 Trauma ‣ Bag-mask ventilation during RSI   ‣ Cricoid pressure Curved blunt dilator Tracheal hook ‣ Manual in-line immobilization       ‣ ASA Difficult Airway Guidelines Trousseau tracheal dilator   Final CVCI option in airway algorithms Methods include need percutaneous, and sur Perform in inferior port Universal cricothyrotom catheter set Studies are lacking   ‣ Role of anesthesiologist Movement of the neck d   Ease of cric with MILS   Neurological deterioratio
  60. 60. 61 Summary ‣ Algorithms only serve as guidelines ‣ Be cognizant of predictors of the DA ‣ Equipment must be available ‣ Acquire & maintain advanced airway management skills ‣ Do what works best for you ‣ You CAN make a difference!!
  61. 61. 62 Aphorisms Practice is the best of all instructors. The better you are, the luckier you become. We live a life of choice, not chance. ASA NEWSLETTER Abouleish EI. Moments With The Pen. <>
  62. 62. 63
  63. 63. 64 BVM Ventilation Prior to Intubation Difficult to achieve adequate preoxygenation High risk of arterial desaturation Pre-existing conditions - Obesity Lung injury Altered LOC Combativeness
  64. 64. 65 Cricoid Pressure Removed as a Level I recommendation May worsen laryngoscopic view Impair bag-valve mask (BVM/ventilation) Not reduce incidence of aspiration Recommendation: Apply throughout induction and intubation attempts if necessary, alter/remove to ease intubation or SGA insertion.
  65. 65. 66 Cervical Spine Manual In-Line Stabilization (MILS) Inferior view/longer time or failure to secure airway Recommended by ATLS guidelines No outcome data demonstrating inferior Benefits should be balanced against potential for hypoxic damage
  66. 66. 67 Video Laryngoscopy Does VL reduce cervical motion compared to DL in patients w/ known or suspected CSI? ! Is there improved intubation success rate in the trauma patient?
  67. 67. 68 Airway Management Controversies Trauma Care ! ‣ Common problems - ! ! Hemodynamic instability Time pressure Lack of patient cooperation Risk of aspiration Need for cervical spine protection Facial injuries Limited options (can’t wake up/ cancel case)
  68. 68. 69 Good decisions come from experience Unfortunately experience often comes from bad decisions