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Emergency Airway Skill Training IV Course 2013

Assessment Of The
Upper Airway

NIK AHMAD SHAIFFUDIN BIN NIK HIM
MD., MMed...
Presentation Outline
1. Introduction
2. Airway Revisited
–

Adult vs Pediatric Airway

1. Approach to upper airway assessm...
Most of us already know
this much

On going learning
and professional
skills development

After E.A.S.T. (hopefully)

DISC...
INTRODUCTION
• Airway assessment & management ….. The single
most important skill for ECP
• “A” in the ABC of resuscitatio...
AIRWAY REVISITED
Understanding The Airways
Anatomical hollow canals that allow
the passage of air into and outside
the res...
Understanding The Airways
Functional anatomy is important to
expert airway management…
A clear understanding will…
o
o
o
o...
Middle Airway

Lower Airway
Important distances in adult:
Incisor teeth to vocal cords 15 cm
Incisor teeth to carina
20 cm
External nares to carina
30...
Adults VS Pediatric Airway :
Anatomy & Physiology

The Pediatric Airway:
“They’re not just little adults!”
Anatomical Differences….
Anatomical Differences…cont
PHYSIOLOGICAL DIFFERENCES
Infant
1.
2.
3.
4.
5.
6.

Fewer alveoli
Increase oxygen consumption
...
Physiology
• Kids desaturate fast!
Ron Walls, MD
“Manual of Emergency Airway Management”
APPROACH TO UPPER
AIRWAY ASSESSMENT
Purpose Of Airway Assessment….
1. Look for potential or
compromised airway
2. Need for basic airway adjuncts
3. Suitabilit...
In emergency setting….

How do you know if the airway is patent……
When to secure it?
Is your patient is going to be diffic...
Approach To Emergency Upper
Airway Assessment…. General
1. SPEECH

Speak to your patient !!!
Patency & Adequacy
What is yo...
Approach To Emergency Upper
Airway Assessment…. General
2. LOOK…..

Consciousness - full, alternating, reduced
Respiratory...
Predictors: Medical History
• Joint disease
• Acromegaly
• Thyroid or major neck
surgeries
• Tumors, known abnormal
struct...
Difficult Airways…

Look For Predictors & Risks
– Believe the history of previous difficult airway
management…..
– All air...
Difficult Airway …..
Risk Assessment
• Assessing & Identifying a
potentially difficult airway
is essential to preparing
an...
Recognizing Difficult
Airway
1. Difficult laryngoscopy &
intubation

3. Difficult Extraglottic
Device (EGD)

Four Dimensio...
1. Difficult Laryngoscopy &
Intubation
……Quick Assessment
Subjective clinical judgment can be highly specific (>90%), but ...
LOOK Externally
•
•
•
•
•
•
•

Facial or neck trauma
Large incisors/ broken teeth
Beards or facial hair
Protruding tongue
...
EVALUATE 3-3-2
•

•

•

Will patients mouth open
wide enough to
accommodate 3 fingers?
Will 3 fingers fit between
the ment...
Incisors distance ( Mouth opening)
Distance -3 fingers?

Hyoid-mentum ( Length of mandible)
Distance -3 fingers?

LEMONS
LEMONS

Hyoid to the thyroid notch
Distance- 2 fingers ?

•

•

Patients who have a longer Hyoid to
thyroid distance, grea...
Upper & Lower Face
• Size upper face = lower face …..
• Lower face > upper face then you
should anticipate some degree of
...
INTUBATION FAILURE

LEMONS

LOW

HIGH
Mallampati Score ???

LEMONS
Obstruction
• Laryngoscopy or intubation may be
more difficult in the presence of an
obstruction
–
–
–
–

Anatomy
Trauma
F...
Obstructions
Laryngoscopic View Grades
Grade 1:
Grade 2:
Grade 3:
Grade 4:

Full aperture visible
Lower part of cords visi...
LEMONS
Cormack & Lehane Grading
Grade I = ↑
success & ease
of intubation

10-30%

<5%

% listed = incidence

<1%
Neck Mobility

LEMONS

• Ideally the neck should be able to extend back
approximately 35°
• Problems:
–
–
–
–

Cervical Sp...
Scene and Situation (SEE)

LEMONS

• Scene safety
• Environment
– Do you have a reasonable chance to get the tube?
– Space...
2. Difficult to Bag & Mask
Ventilation (MOANS)
“The clinical situation where using 100% oxygen and bag/valve/mask ventilat...
Mask Seal
•
•
•
•
•
•

Oddly Shaped Face
Bushy Beard
Blood/Vomit
Facial Trauma
Small Hands
Wrong Mask Size

MOANS
Obesity or Obstruction
• Obesity
–
–
–
–

Increased supraglottic airway resistance
Billowing cheeks
Difficult mask seal
Ab...
Obesity or Obstruction

MOANS

• 3rd Trimester Pregnancy
–
–
–
–

Increased Mallampati Score
Gravid uterus inhibits moveme...
Obesity or Obstruction
• Obstructions
–
–
–
–
–
–

Foreign Body
Angioedema
Abscesses
Epiglottitis
Cancer
Traumatic Disrupt...
Age > 55

MOANS

• Associated with BVM difficulty, possibly due to
loss of tone in the upper airway
No Teeth

MOANS

• Face tends to “cave in”
• Consider leaving dentures in for BVM and remove
for intubation
Stiff
• Refers to Poor Compliance
–
–
–
–

Reactive Airway Disease
COPD
Pulmonary Edema/Advance Pneumonia
History of Snori...
Difficult EGD RODS
RO-

Restricted mouth opening
Obstruction : Obstruction at the level of larynx or
below EGD will not pa...
Difficult Cricothyrotomy
SHORT

• No absolute contraindications to performing
emergency cricothyrotomy…
• Time is “SHORT” ...
Difficult Cricothyrotomy
• The evidence is clear that….. When emergency
surgical airway is required, it is not the procedu...
“BURP” – a.k.a.
“External Laryngeal Manipulation”
• Backward, Upward,
Rightward Pressure:
manipulation of the
trachea
• 90...
TAKE HOME MESSAGES
1. Upper airway assessment is a critical part of the RSI
process …. Assess every airway for difficulty ...
TAKE HOME MESSAGES
4. If your assessment suggest risk for difficult
airway and are frantically looking for a difficult
air...
TAKE HOME MESSAGES
7. If assessment anticipated deterioration &
compromised airway of the critically ill or injured
……intu...
“ Good Judgment may come from
experience but experience comes
from bad judgment “..…

Mark Twain
Any questions?
Its spot the difficult
airway patient time!
Look at you partner
now. Difficult?
1.
2.
3.
4.
5.
TQ…
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  1. 1. Emergency Airway Skill Training IV Course 2013 Assessment Of The Upper Airway NIK AHMAD SHAIFFUDIN BIN NIK HIM MD., MMed (Emerg.Med. USM), AMM Hospital Sultanah Nur Zahirah drnikahmad@gmail.com
  2. 2. Presentation Outline 1. Introduction 2. Airway Revisited – Adult vs Pediatric Airway 1. Approach to upper airway assessment – – General…. Recognizing difficult airway 4. Take Home Messages
  3. 3. Most of us already know this much On going learning and professional skills development After E.A.S.T. (hopefully) DISCLAIMER: Hold you horses! You ain’t getting a full license at the end of the course!
  4. 4. INTRODUCTION • Airway assessment & management ….. The single most important skill for ECP • “A” in the ABC of resuscitation…. Without a secure airway and adequate oxygenation the other resuscitative measures are doomed to failure • With the exception of immediate defibrillation in cardiac arrest patient….. No single resuscitative maneuver takes priority over the airway assessment & management!!
  5. 5. AIRWAY REVISITED Understanding The Airways Anatomical hollow canals that allow the passage of air into and outside the respiratory system Divided into upper and lower airways; the arbitrary border is the glottis • Upper airway has muscular, bony and cartilaginous part • Lower airways is almost all smooth muscle Upper Lower
  6. 6. Understanding The Airways Functional anatomy is important to expert airway management… A clear understanding will… o o o o Guide the choice of intubation Enhanced the best approach Basis for avoiding complications …..… early detection Upper Airway
  7. 7. Middle Airway Lower Airway
  8. 8. Important distances in adult: Incisor teeth to vocal cords 15 cm Incisor teeth to carina 20 cm External nares to carina 30 cm *+/- 1 to 2 cm
  9. 9. Adults VS Pediatric Airway : Anatomy & Physiology The Pediatric Airway: “They’re not just little adults!”
  10. 10. Anatomical Differences….
  11. 11. Anatomical Differences…cont PHYSIOLOGICAL DIFFERENCES Infant 1. 2. 3. 4. 5. 6. Fewer alveoli Increase oxygen consumption Rate dependant Diaphragmatic dependant High airway resistance Infant is more vulnerable to respiratory muscle fatigue
  12. 12. Physiology • Kids desaturate fast!
  13. 13. Ron Walls, MD “Manual of Emergency Airway Management”
  14. 14. APPROACH TO UPPER AIRWAY ASSESSMENT
  15. 15. Purpose Of Airway Assessment…. 1. Look for potential or compromised airway 2. Need for basic airway adjuncts 3. Suitability for NIV 4. Candidacy for definitive airway or IPPV 5. Emergency surgical airway 6. Clues to diagnosis or etiology and its subsequent management
  16. 16. In emergency setting…. How do you know if the airway is patent…… When to secure it? Is your patient is going to be difficult for definitive airway…? …… and does it really matter?
  17. 17. Approach To Emergency Upper Airway Assessment…. General 1. SPEECH Speak to your patient !!! Patency & Adequacy What is your name ? Or Boleh saya bantu ? Response provides information both airway and neurological status!! ….. Suggestive the airway is patent and adequate for the time being!!!!
  18. 18. Approach To Emergency Upper Airway Assessment…. General 2. LOOK….. Consciousness - full, alternating, reduced Respiratory effort - normal, increased or reduced Do they just look difficult? •Dentition (prominent upper incisors, receding chin) •Distortion (edema, blood, vomits, tumor, infection) •Disproportion (short chin-to-larynx distance, bull neck, large tongue, small mouth) •Dysmobility (TMJ and cervical spine) •Distance ( Sternomental > 12 cm, Thyroidmental > 7 cm…) Oxygenation - Respiratory rate and SPO2 read together Capnograph…. 3. LISTEN… Phonation, snore, stridor, wheeze, gargles etc Try to get airway history…… if possible !!!
  19. 19. Predictors: Medical History • Joint disease • Acromegaly • Thyroid or major neck surgeries • Tumors, known abnormal structures • Genetic anomalies • Epiglottitis • Previous problems in surgery • Diabetes • Pregnancy • Obesity Ron Walls, MD, “Manual of Emergency Airway Management”
  20. 20. Difficult Airways… Look For Predictors & Risks – Believe the history of previous difficult airway management….. – All airway management techniques fail and this is often unanticipated !!!! – Never fail to prepare for failure – Even a thorough advance evaluation will help you identify difficult airways only about 50% of the time ACEP Ron Walls, MD, “Manual of Emergency Airway Management” M. Rosen & I.P.Latto 1984 , British Journal Of Anesthesia
  21. 21. Difficult Airway ….. Risk Assessment • Assessing & Identifying a potentially difficult airway is essential to preparing and developing a strategy for successful ETI and also preparing an alternate plan in the event of a failed ETI. Ron Walls, MD, “Manual of Emergency Airway Management”
  22. 22. Recognizing Difficult Airway 1. Difficult laryngoscopy & intubation 3. Difficult Extraglottic Device (EGD) Four Dimensions of Airway Difficulties 2. Difficult to ventilate with a BVM 4. Difficult to perform cricothyrotomy Ron Walls, MD, “Manual of Emergency Airway Management”
  23. 23. 1. Difficult Laryngoscopy & Intubation ……Quick Assessment Subjective clinical judgment can be highly specific (>90%), but severely insensitive (<20%) and so must be augmented by other evaluations Dr. Binnions Lemon Law: An easy way to remember multiple test • • • • • • Look externally. Evaluate the 3-3-2 rule. Mallampati. Obstruction? Neck mobility Scene & Situation Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed., Copyright © 2006 Mosby, Inc
  24. 24. LOOK Externally • • • • • • • Facial or neck trauma Large incisors/ broken teeth Beards or facial hair Protruding tongue Short, fat neck Morbidly obese Dysmorphism LEMONS
  25. 25. EVALUATE 3-3-2 • • • Will patients mouth open wide enough to accommodate 3 fingers? Will 3 fingers fit between the mentum and hyoid bone? Will 2 fingers fit between the hyoid and thyroid notch? – If not, expect a difficult intubation LEMONS
  26. 26. Incisors distance ( Mouth opening) Distance -3 fingers? Hyoid-mentum ( Length of mandible) Distance -3 fingers? LEMONS
  27. 27. LEMONS Hyoid to the thyroid notch Distance- 2 fingers ? • • Patients who have a longer Hyoid to thyroid distance, greater then 2 finger widths, tend to be more difficult to intubate. A more caudal hyoid bone thus indicates a relatively caudal larynx.
  28. 28. Upper & Lower Face • Size upper face = lower face ….. • Lower face > upper face then you should anticipate some degree of difficulty lining up the structures. LEMONS
  29. 29. INTUBATION FAILURE LEMONS LOW HIGH
  30. 30. Mallampati Score ??? LEMONS
  31. 31. Obstruction • Laryngoscopy or intubation may be more difficult in the presence of an obstruction – – – – Anatomy Trauma Foreign body obstruction Edema (burns) LEMONS
  32. 32. Obstructions Laryngoscopic View Grades Grade 1: Grade 2: Grade 3: Grade 4: Full aperture visible Lower part of cords visible Only epiglottis visible Epiglottis not visible LEMONS
  33. 33. LEMONS Cormack & Lehane Grading Grade I = ↑ success & ease of intubation 10-30% <5% % listed = incidence <1%
  34. 34. Neck Mobility LEMONS • Ideally the neck should be able to extend back approximately 35° • Problems: – – – – Cervical Spine Immobilization Ankylosing Spondylitis Rheumatoid Arthritis Halo fixation
  35. 35. Scene and Situation (SEE) LEMONS • Scene safety • Environment – Do you have a reasonable chance to get the tube? – Space, positioning, access • Egress – Will you be able to ventilate during egress? – A respiratory rate of 4 is better than a rate of 0! – Enough meds for a long extrication?
  36. 36. 2. Difficult to Bag & Mask Ventilation (MOANS) “The clinical situation where using 100% oxygen and bag/valve/mask ventilation, an unassisted anesthesiologist is unable to maintain oxygen saturation greater than 90% in a person who was capable of doing so before intervention” Estimated that up to 28% of all anaesthetic related deaths are secondary to the inability to mask ventilate or intubate. • • • • • Mask Seal Obesity or Obstruction Age > 55 No Teeth Stiff Practice Guidelines for Management of the Difficult Airway. ASA Taskforce. Anesthesiology 2003; 98:1269-1277
  37. 37. Mask Seal • • • • • • Oddly Shaped Face Bushy Beard Blood/Vomit Facial Trauma Small Hands Wrong Mask Size MOANS
  38. 38. Obesity or Obstruction • Obesity – – – – Increased supraglottic airway resistance Billowing cheeks Difficult mask seal Abdominal contents inhibit movement of the diaphragm – Quicker desaturation – Heavy chest MOANS
  39. 39. Obesity or Obstruction MOANS • 3rd Trimester Pregnancy – – – – Increased Mallampati Score Gravid uterus inhibits movement of the diaphragm Quick desaturation Increased body mass
  40. 40. Obesity or Obstruction • Obstructions – – – – – – Foreign Body Angioedema Abscesses Epiglottitis Cancer Traumatic Disruption/Hematoma/Burns MOANS
  41. 41. Age > 55 MOANS • Associated with BVM difficulty, possibly due to loss of tone in the upper airway
  42. 42. No Teeth MOANS • Face tends to “cave in” • Consider leaving dentures in for BVM and remove for intubation
  43. 43. Stiff • Refers to Poor Compliance – – – – Reactive Airway Disease COPD Pulmonary Edema/Advance Pneumonia History of Snoring/Sleep Apnea • Also predicts a higher Mallampati score MOANS
  44. 44. Difficult EGD RODS RO- Restricted mouth opening Obstruction : Obstruction at the level of larynx or below EGD will not pass this obstruction D - Disrupted or distorted airway : Fail to “seat & seal” SStiff lungs or cervical spine: Ventilation difficult due to airway resistance, poor lungs compliance and difficult insertion due to limited neck movements.
  45. 45. Difficult Cricothyrotomy SHORT • No absolute contraindications to performing emergency cricothyrotomy… • Time is “SHORT” when cricothyrotomy is indicated!! S - Surgery H - Hematoma O - Obesity R - Radiation T - Tumor
  46. 46. Difficult Cricothyrotomy • The evidence is clear that….. When emergency surgical airway is required, it is not the procedures that kills the patients, but delaying or not doing it causes harm !! • Do what you can do BUT do not do what you cannot do. Ask for help !!!.... Airway management should suit the patient NOT the Dr, Nurse or Paramedics !! Dr Cook & Dr MacDouglass-Davis , British Journal of Anesthesia
  47. 47. “BURP” – a.k.a. “External Laryngeal Manipulation” • Backward, Upward, Rightward Pressure: manipulation of the trachea • 90% of the time the best view will be obtained by pressing over the thyroid cartilage Differs from the Sellick Maneuver
  48. 48. TAKE HOME MESSAGES 1. Upper airway assessment is a critical part of the RSI process …. Assess every airway for difficulty !!! 2. Believe the history of difficult airway management 3. Assess for the unexpected !!!. Hypoxia is the killer… avoid it.
  49. 49. TAKE HOME MESSAGES 4. If your assessment suggest risk for difficult airway and are frantically looking for a difficult airway equipment/ device you ought to be looking (or calling) for your consultant quickly too. 5. ETCO2 post-intubation was mandatory since 10 years ago! Please use. 6. Arterial blood gas values are rarely helpful in the emergence decision to intubate and may be misleading …..
  50. 50. TAKE HOME MESSAGES 7. If assessment anticipated deterioration & compromised airway of the critically ill or injured ……intubate early before it occurs!! 8. It is better to err by identifying an airway as potentially difficult, only to subsequently find it is not….. than the other way around !!! 9. While this criteria helps identify difficult airways, it does not guarantee an easy intubation — Be Prepared !!!!
  51. 51. “ Good Judgment may come from experience but experience comes from bad judgment “..… Mark Twain
  52. 52. Any questions?
  53. 53. Its spot the difficult airway patient time!
  54. 54. Look at you partner now. Difficult?
  55. 55. 1.
  56. 56. 2.
  57. 57. 3.
  58. 58. 4.
  59. 59. 5.
  60. 60. TQ…
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