AIRWAY MANAGEMENT IN POST BURN CONTRACTURE/PBC & TMJ ANKYLOSIS

1. DR ZIKRULLAH

2. POST BURN CONTRACTURE

3. Classification of burns?

4.  1st degree : upper layer of epidermis. Skin painful
and red.
 2nd degree : extend to dermis. Very painful
blisters. Regenerate to new skin.
 3rd degree : destruction all layers of skin including
nerve endings. Painless; no regeneration.
 4th degree : all skin layers, muscle, fascia, may
even reach bones.

5. Types of post burn contracture?

6. J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 25/June 22, 2015 Page 3755

7. 1

8. Airway assessment?

9.  ‘BONES’ for assessing difficulty at mask ventilation
(Beard, obesity, no teeth, elderly, snorer)
 ‘LEMON’ for assessing difficulty during laryngoscopy
& intubation
(Look externally, examine 3-3-2,MMP, obstruction,
neck mobility)
 ‘RODS’ for assessing difficult placement of SAD
(Restricted mouth opening, obstruction, disrupted
upper airway, stiff lung)
 ‘BANG’ to predict difficult surgical airway
(Bleeding tendency, agitation, neck scarring, growth
or vascular abnormalities in region)

11. What are the problems in airway
management in PBC?

12. Difficulty in securing ETT
 Restricted mouth opening.
 Narrow nasal passage.
 Stiff submandibular space.
 Decreased oropharyngeal space.
 Distortion in anatomic alignment of Oro-
pharynx, pharynx and trachea.
 Cervical spine distortion.
 Fixed flexion neck deformity.
 Inability of atlanto-occipital extension.

13. Muscle relaxants:-
 Succinyl choline massive release of intracellular
K+ dangerous hyperkalemia
 Starts after 1st week and last up to 6 months.
 NDMR is safer if no predictors of difficult intubation.
 Patients with >30% burn area may manifest
resistance to NDMR. Due to proliferation of extra
junctional receptors.
 Seen after 1 week and last up to 3-6 months.

14. Other difficulties
 Securing IV lines.
 Applying monitors in patients with limb and chest
wall burns.

15. Is there any NDMR whose activity not
affected in burn patients?

16.  Mivacurium (0.2mg/kg)
 Degraded by plasma cholinesterase, whose
activity is decreased in burns.

17. What are the different options of
airway management ?

18.  Conventional intubation if mild contracture.
 Awake FOI (nasal or oral)
 If mouth opening >2 finger ILMA+ETI in awake
patient.
 If mouth opening >2 finger LMA classic can be used.
 New generation video laryngoscopes : as blade height
is significantly less.
 Combitube .
 Pre-induction scar release under ketamine
anaesthesia or local anaesthesia + hyaluronidase
infiltration then tracheal intubation.

19.  FOI is Gold standard
 If inadequate mouth opening LMA can’t be inserted.
 If neck movement is restricted blind nasal intubation
will be difficult.

20. Preparations for awake fiberoptic
intubation?

21.  Psychological preparation of patient.
 Procedure and post operative numbness should be
explained.
 Premedicate with Inj. Glycopyrolate 0.2mg IV
 Inj. Midazolam 0.02-0.03mg/kg: sedation and amnesia.
 Fentanyl 1-2mcg/kg: analgesia for blocks, reduce
airway response to manipulation and reduce
discomfort and haemodynamic changes to intubation.
 Dexmedetomidine also been used for achieving
optimal sedation

22. Rules for acheiving just optimal
sedation/analgesia for awake
intubation?

23.  Judicious titration: don’t give boluses of drugs.
 Avoid multiple drugs.
 Try to use drugs that have reversal agent.

24. L.A for awake fiberoptic intubation?

25.  Xylocaine most commonly used
 3-4mg/kg used via nebulizer
 Rest 3-4mg/kg for direct mucosal application,
blocks and infiltration some direct through
bronchoscope ( spray-as-you-go-technique)

26. Superior laryngeal nerve block?

27.  Branch of vagus ; sensation to epiglottis,
arytenoids and vocal cords.
 Needle is inserted through the skin on to lateral
portion of hyoid bone, walked off inferiorly and
advanced through thyrohyoid membrane.
 Resistance is felt as needle passes through
membrane.
 2-3 ml of 1% xylocaine injected bylaterally.
 Duration lasts 20-30min with plain and up to 2hrs
with adrenaline. So patient can be at increased
risk of aspiration until normal function returns.

28. Internal laryngeal nerve block?

29.  Cotton pledges soaked in 4% xylocaine are
placed in pyriform fossa, with curved tonsillar
forceps, for 2 min.

30. Local anaesthesia of trachea
below vocal cords
 Cricothyroid membrane identified and a 23
guage needle with 2-3ml 2% xylocaine is
advanced until loss of resistance felt.
 Placement within trachea is identified with
aspiration of air.
 Drug is injected rapidly and needle withdrawn.
 Vigorous coughing helps spread of drug to under
the volacal cords and trachea and carina.

31.  Nebulized xylocaine provide satisfactory
anaesthesia from nose or mouth to below vocal
cords.
 For patients above 30kg 5ml of 4% xylocaine is
safe.
 Advantage of nebulized xylocaine against direct
topical administration is reduced serum xylocaine
level.

32. “ADD a TSP”
 Adequate explanation of need of procedure
 Decongestion of nasal passage using
vasoconstrictors.
 Drying up secretion by using glycopyrolate.
 Topicalisation of upper airway by nebulisation,
gargles and local spray.
 Sedation and anxiolysis: midazolam and
remifentanyl
 Patience, patience and patience

33. Tumescent L.A?

34.  Described for scar release.
 Mixture of 30 ml of 2% Lidocaine;
 1mg epinephrine (1:1000)
 1ml of hyaluronidase containing 1500 IU
 450ml RL
 70-200ml of final mixture is used for release of
scar
 Targeted tissue become swollen, firm or
tumescent and permits procedures to be
performed.

36. Associated problems secondary to
TMJ ankylosis?

37.  Nutrition problems.
 Poor oral hygiene leading to dental decay /
abscess.

38. Etiopathogenesis of TMJA?

39.  Trauma
 Infection
 Rheumatoid arthritis
 Congenital deformity

40. Investigations needed to confirm
the diagnosis?
 MRI : investigation of choice
 Conventional radiography (transcranial view)
 CT with mouth open and closed positions
 Arthrography using contrast media into joint
spaces.
 ESR, autoantibodies, uric acid level

41. Airway management difficulties in
partial restriction of TMJ function?

42.  Restriction of the movement of tongue preventing
tongue displacement.
 Hinders instrumentation such as rigid
laryngoscopy.
 Minimum mouth opening required for SAD like
LMA, ILMA, Combitube... is approx. 2cm.

43. Nasotracheal intubation techniques?

44.  Fiberoptic nasotracheal intubation would be
the technique of choice.
 Seeing optic stylet system (SOS), akin to
lightwand with exception that it has fiberoptics
incorporated in the wand with an eyepiece,
aided nasotracheal intubation.
 Flexible airway scope tool (FAST) aided
intubation. Similar to SOS.
 Retrograde nasotracheal intubation.
 Blind nasotracheal intubation.

45. SHIKANI SEEING OPTICAL STYLET

46. Anaesthetic options for achieving NTI?

47.  Awake intubation under topical / nerve block
anaesthesia using mild sedation + drying agent is
safest technique.
 If patient is paediatric or uncooperative,
intubation can be done under
 Inhalational anaesthesia
 Inhalational + muscle relaxant

48. If patient goes into CVCI situation while
trying NTI what’s the next step?

49.  Cricothyrotomy with transtracheal jet ventilation.
 Needle cricothyrotomy would be the fastest
technique to restore oxygenation.
 Percutaneous cricothyrotomy should be reserved
for an elective situation.
 Surgical cricothyrotomy should be the last option

50. Precautions to be taken prior to
extubation?

51.  Extubate when patient is fully awake
 Wait for complete reversal of the residual NMB
 Extubate over a ventilating stylet / AEC

52. AIDAA 2016 Guidelines for
management of unanticipated
difficult intubation

53. PRE-OPERATIVE ASSESSMENT AND
PREPARATION
 Identify factors for difficult ventilation, SAD
insertion, intubation and emergency surgical
access.
 Be prepared for a difficult airway at all times.
 Reduction of the gastric volume and increase in
pH.
 NG suction in case of delayed emptying.

54.  Pre-operative sedation should be used with
caution in anticipated difficult airway.
 In patients with a compromised airway sedation
is best avoided.

55. Technique of pre oxygenation?

56.  20° head - up position unless contraindicated.
 Ensure a proper face mask fit.
 3 min with tidal volume breathing.
 5 min if a mask leak is present.
 Nasal cannula oxygen supplementation improve
the efficacy of pre-oxygenation if there is a mask
leak.

57.  Pre-oxygenation with 8 vital capacity breaths
for 1 min is more effective.
 Pre-oxygenation following forced exhalation
followed by tidal breathing is also more
effective.
 Target an end-tidal oxygen >90% and end-tidal
nitrogen <4%.

58.  Delivery of at least 10 L/min of O2 with an open
circuit or O2 prefilled closed circuit is mandatory.
 CPAP of 5–10 cm H2O is recommended, if not
contraindicated.
 Pressure support ventilation of 5–15 cm H2O
should be applied if possible.
 Non-invasive ventilation improves the
effectiveness.

59.  Apnoeic oxygenation using a nasal cannula with
oxygen at 10–15 L/min into pharynx through
nasal cannula, airway or catheter can extend the
duration of safe apnoea time after muscle
relaxants are used.
 The nasal cannula can be placed under a
facemask during pre-oxygenation, and then it
can be used to administer nasal oxygen during
tracheal intubation.
 Not only in anticipated difficult airway but also
during all intubations.

60.  When difficulty is encountered during mask
ventilation, consider changing to a mask with a
better fit.
 Optimise position, and use airway manoeuvres
such as head tilt, chin lift or jaw thrust or
two-handed mask holding.
 Consider using adequately-sized oropharyngeal
or nasopharyngeal airways.

61. THRIVE?

62. Transnasal Humidified Rapid Insufflation
Ventilatory Exchange
 Oxygen (100%) at 70 L/min is used for
pre-oxygenation and continued during
induction and after giving neuromuscular
blockade to provide apnoeic oxygenation, until
a definitive airway is secured.
 This requires dedicated equipment with oxygen
humidification unit, nasal oxygen cannula and
tubing connecting standard oxygen regulator to
the transnasal oxygen cannula.

63.  It provides CPAP with gas exchange by
flow-dependent flushing of the dead space.
 Significantly prolongs the safe apnoea time.

64. Induction agent and neuromuscular
blockade
 Depend on the clinical situation and the
condition of the patient.
 Propofol suppresses the laryngeal reflexes,
providing better intubating conditions as
compared to other agents.
 Ensure adequate depth of anaesthesia during
repeated attempts at intubation to prevent
awareness.

65.  Neuromuscular block results in apnoea,
abolishes the laryngeal reflexes, improves chest
wall compliance.
 Improve the chances of successful airway
management when face mask ventilation is
difficult.
 During RSI, either rocuronium or succinylcholine
may be used.

66.  Rocuronium ≥1.2 mg/kg, intubating conditions
equivalent to those of succinylcholine are
achieved within 60 s.

67. Intubation
 Repeated attempts can result in airway trauma
and increase the risk of progressing to a ‘cannot
ventilate’ situation.
 Attempts should be limited to the minimum
(max. 3 attempts) and repeated only if the
oxygen saturation is ≥95%.

68.  If the first attempt is difficult, change the plan
during subsequent attempts, rather than
repeatedly performing the manoeuvres that
have failed.
 This may involve changing the position,
intubating device and using additional tools or
manoeuvres.
 OELM may improve the laryngoscopic view.
 A pre-shaped stylet or gum-elastic bougie may
be used to facilitate tracheal intubation in
Grade 2b and 3a laryngeal view

69.  Blind insertion in Grade 3b or 4 direct
laryngoscopic view is not recommended as it
can lead to trauma.
 If ET tube get held up at the arytenoids while
railroading, rotate the ET tube anticlockwise to
change the direction of the bevel or keep the
bevel facing posteriorly while pre-loading the
tube or reduce the space between the
bronchoscope and the ET tube.

70. How will you confirm endotracheal
intubation?

71.  Visual confirmation of the ET tube between
the vocal cords
 Bilateral chest expansion
 5-point auscultation
 Capnography (gold standard) : 6 consistent
capnograph traces without any decline in the
detected CO2 levels.

72. Role of SAD as a rescue device during
a difficult airway?

73.  Placement of a SAD helps in maintaining
oxygenation and gives us time to think about
a further management plan.
 2nd generation SADs with the higher sealing
pressures and tube for gastric drainage should
be preferred.
 Cricoid pressure should be removed.
 Recommend a maximum of two attempts at
SAD insertion.

74.  Intubation through SAD should only be
performed under vision, using a fibreoptic
bronchoscope only.

75. CALLING FOR HELP
 Calling for help should be done at the earliest
when the first difficulty in airway management
is encountered.
 The AIDAA recommends calling for additional
help when the final attempt at rescue mask
ventilation fails and emergency
cricothyroidotomy is planned.

76. Emergency cricothyroidotomy
 Deemed necessary when there is CVF, when
intubation, ventilation using SAD and face
mask have also failed after giving the best
attempt, even though oxygenation may be
maintained.

77.  Identify and mark the cricothyroid membrane
before induction of anaesthesia in patients
with an anticipated difficult airway.

78. Laryngeal handshake?

79.  Described by Levitan.
 First, the hyoid and thyroid laminae are
identified using the non-dominant hand.
 Then, larynx is identified and stabilised
between the thumb and the middle finger,
and then the neck should be moved down to
palpate the cricothyroid membrane with the
index finger.

81. Techniques for cricothyroidotomy?

82.  Surgical cricothyroidotomy
 Non-surgical/needle cricothyroidotomy
 Narrow-bore (usually an internal diameter of
≤4 mm) cannula-over-needle technique
(14-/16-gauge cannula)
 Wide-bore(usually internal diameter ≥4 mm)
cannula-over-trocar
 A wire-guided technique (Seldinger).

83.  National Audit Project 4 (UK) reported a
success rate of 37% with narrow-bore
cannula-over-needle cricothyroidotomy, 57%
with wide-bore cannula and 100% with
surgical cricothyroidotomy.

84. Surgical cricothyroidotomy?

85.  ‘stab, twist, bougie, tube’
 Nasal oxygenation at 15 L/min flow rate and
attempts to ventilate by face mask are continued.
 Keeping the blade perpendicular to the skin,
perform a transverse stab incision through the skin
and cricothyroid membrane (lower half of the
membrane).
 Rotate the blade by 90° with sharp edge of the
blade facing caudally.

86.  Stabilise the blade with left hand, provide
gentle traction towards the operator and
insert the bougie 10–15 cm into the trachea.
 The blade must be removed, cuffed ET tube
should be railroaded over the bougie and the
bougie must be withdrawn gently.
 Inflate the cuff and confirm tube position
using capnography.

87.  where cricothyroid membrane is not palpable or
the initial failure occurs
 ‘scalpel–finger–bougie’
 A vertical midline skin incision of around 8–10 cm
is made and enlarged with blunt dissection using
the finger.

88. Limitations of Narrow-bore
cannula technique?

89.  It requires jet ventilation using a high-pressure
ventilation source and associated breath
stacking, barotrauma (pneumothorax,
pneumomediastinum)
 Catheter kinking
 Malposition or dislodgement.
 Not being a definitive airway, the risk of
aspiration is present
 This technique requires a patent upper airway
for exhalation

90.  Jet ventilation provides a short window for
oxygenation, during which tracheostomy
should be performed at the earliest.

91. DIFFICULT AIRWAY CART ?

96. Algorithm for unanticipated
difficult airway

99. Algorithm for difficult
extubation

102.  Assessment of any potential difficult
airway, neuromuscular, respiratory or
cardiovascular compromise.
 If yes, use the difficult extubation
algorithm; if no, proceed for extubation
after antagonising residual neuromuscular
blockade and switching off the volatile
anaesthetic agent

103.  Assess the criteria for extubation
 Perform extubation and monitor the patient
 Supplement oxygen using appropriate oxygen
delivery devices.
 The flow, fraction of inspired oxygen and
duration may be individualised as per patient
requirements

104.  AIDAA recommends that a cuff-leak test is
performed in patients who have a potential to
develop airway oedema or collapse.

105. How to perform quantitative
cuff leak test?

106.  Cuff-leak test measures the difference in
exhaled tidal volumes with the cuff inflated
and deflated.
 This measurement should be done when the
patient is still on volume control mechanical
ventilation.
 The difference between the inflated and
deflated exhaled tidal volumes is considered
significant if it is <10%–25% or 110–130 mL.

107.  This is indicative of oedema or collapsibility
and likely maintenance of a patent airway
following extubation is a doubtful.
 If leak is present, trachea could be extubated
over an AEC/FOB.
 To increase the oxygen reserve, lung
recruitment (if not contraindicated) should be
performed and 100% oxygen supplementation
should be continued during the extubation
process.
 If leak is absent or equivocal, then extubation
should be delayed.

108.  The Difficult Airway Society (UK) recommends
retaining the AEC for 2 h, but the device may be
kept for an extended period of up to 2 days.
 If patency of airway is absent or doubtful, the
ETT should be reinserted and the patient needs
to be reassessed and further extubation plan
formulated.

109. Drugs used for suppression of the
responses during extubation
 Topical lignocaine 10%
 IV β-blockers (esmolol 1.5 mg/kg, 2–5
min before extubation)
 Lignocaine 1 mg/kg over 2 min
 Fentanyl 0.5–1 μg/kg
 Dexmedetomidine 0.75 μg/kg
administered 15 min before extubation.

110. Techniques of exchanging an ETT
for a SAD
 Removal of ETT and insertion of SAD blindly
 Insertion of SAD with ETT in situ. SAD is placed
behind the ETT, and thereafter, ETT is removed
 Removal of ETT over an AEC and railroading the
LMA through its airway lumen into the pharynx
for its placement.

111. Bailey’s manoeuvre?

112.  Avoid airway stimulation : deep anaesthesia or
neuromuscular blockade is essential
 Perform laryngoscopy and suction under direct
vision
 Insert deflated LMA behind ETT
 Inflate Cuff of LMA
 Deflate cuff and remove ETT whilst maintaining
positive pressure.
 Head up position and allow undisturbed
emergence from anaesthesia.

113. Steps for use of AEC
 The length of AEC Corresponds to length of
the ETT in situ and is approximately 20–22 cm
orally or 26–30 cm nasally
 After applying lubricating jelly over the AEC,
insert the AEC to its appropriate depth
 Withdraw the ETT over the AEC and secure
the AEC
 Continue oxygen supplementation. (1–2
L/min)

114. ???

115. Berman intubating/pharyngeal airway

116. ???

117. Ovassapian airway

118. ???

119. Lee fiberoptic intubating airway

120. ???

121. Williams oral airway intubator

122. THANK YOU