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Difficult Airway Management Current Concepts
1. 1
Difficult
Airway Management
Current Concepts
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
5. 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
6. 6
Prospective Study
All major airway events
over a 1yr period
Anesthesia, ICU, ED
Important insights regarding
airway management
complications
7. 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
8. 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
10. 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
11. 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
18. 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.
19. 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
20. 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
21. 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
24. 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
25. 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
http://www.aagbi.org/sites/default/files May, 2011
32. 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
33. !
!
!
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
http://www.engadget.com/2011/04/16/intubation-botlets-doctors-safely-shove-tubes-down-unconscious/
36. 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
37. 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
38. 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
39. 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
44. 44
Gastro-LT™
Designed for obtaining & maintaining airway
patency during procedures in which gastric
access is desired
Deep sedation or general anesthesia
48. 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
49. 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
50. 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
51. 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
52. 52
Failure to manage the airway continues to be
among the leading anesthesia-related causes of
adverse outcomes in obstetrics
53. “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”
54. 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
55. 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
56. 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
58. 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
59. 59
‣
Needle cric rescue technique of
choice
!
‣
Often unsuccessful
- Barotrauma
- BD
- Death
!
‣
Practitioner must be experienced.
Institute early!!
60. 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
61. 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!!
62. 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. <www.momentswiththepen.com>
64. 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
65. 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.
66. 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
67. 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?
68. 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)
