Airway Manegement


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Airway Manegement

  1. 1. Dr. Husni ajaj Dr.husni
  2. 2. <ul><li>Introduction </li></ul><ul><li>Pathological Conditions </li></ul><ul><li>Avoiding Airway Problems </li></ul><ul><li>Airway Anatomy </li></ul><ul><li>Local Anesthesia of the Airway </li></ul><ul><li>ASA Airway Management Algorithm </li></ul><ul><li>Management Options </li></ul><ul><li>Airway Cart </li></ul><ul><li>Retrograde Intubations Set </li></ul><ul><li>Airway Exchange Catheter </li></ul><ul><li>Melker Cricothyrotomy Set </li></ul><ul><li>Arndt Cricothyrotomy Set </li></ul><ul><li>Patil Cricothyrotomy Set </li></ul><ul><li>References </li></ul>Dr.husni
  3. 3. Introduction <ul><li>Expertise in airway management is important in every medical specialty. Maintaining a patent airway is a vital aspect of providing adequate oxygenation and ventilation. Failure to do so for even a brief period can be disastrous. In fact, excluding dental damage, the single largest category of anesthetic-related injury is respiratory events. The three main causes of respiratory-related injury are inadequate ventilation, esophageal intubation, and difficult tracheal intubation. Other adverse respiratory events are much less common causes of injury. </li></ul>Dr.husni
  4. 4. Airway dificulty Dr.husni
  5. 5. Pathological Conditions <ul><li>Variations in &quot;normal&quot; anatomy and characteristic airway anatomy resulting from pathological conditions can result in problems despite proper positioning and equipment. A small mouth opening, protruding upper teeth, a large tongue, immobility of the head, neck, and jaw all may result in airway difficulty as may the following conditions. </li></ul><ul><li>Conditions that predispose to a difficult airway include: </li></ul><ul><li>Infections </li></ul><ul><li>epiglottitis, abscesses, croup, bronchitis, pneumonia. </li></ul><ul><li>Trauma </li></ul><ul><li>maxillofacial trauma, cervical spine injury, laryngeal injury. </li></ul><ul><li>Endocrine </li></ul><ul><li>morbid obesity, diabetes mellitus, acromegaly. </li></ul>Dr.husni
  6. 6. <ul><li>Foreign Body </li></ul><ul><li>  </li></ul><ul><li>Inflammatory Conditions </li></ul><ul><li>ankylosing spondylitis, rheumatoid arthritis. </li></ul><ul><li>Tumors </li></ul><ul><li>upper and lower airway tumors. </li></ul><ul><li>Congenital Problems </li></ul><ul><li>choanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome, Hallermann-Streiff syndrome. </li></ul><ul><li>Physiologic Conditions </li></ul><ul><li>pregnancy . </li></ul>Dr.husni
  7. 7. Avoiding Airway Problems <ul><li>Intubation difficulty may result from or be due to: </li></ul><ul><li>1.      Incorrect position of the patient. </li></ul><ul><li>2.      Inadequate or improper equipment. </li></ul><ul><li>3.      Unusual or abnormal anatomy. </li></ul><ul><li>4. Pathologic causes. </li></ul>Dr.husni
  8. 8. Larynx and Trachea Dr.husni
  9. 9. Dr.husni
  10. 10. Local Anesthesia of the Airway <ul><li>* Local anesthesia of the airway can minimize discomfort during awake intubation. </li></ul><ul><li>* Awake intubation is desirable in many cases of anticipated difficult intubation. </li></ul><ul><li>* Airway muscle tone and patency are preserved and spontaneous ventilation continues </li></ul><ul><li>* Risk of aspiration is minimized. If the intubation attempt fails, the patient can still breathe. </li></ul><ul><li>* Use sedation with caution during awake intubation </li></ul><ul><li>Discussion of the local anesthesia and intubation techniques with the patient is important to reduce patient anxiety </li></ul>Dr.husni
  11. 11. ASA Airway Management Algorithm <ul><li>The American Society of Anesthesiologists guidelines call for preoperative history and physical examination, preoperative preparation of equipment and preformulated strategy. </li></ul>Dr.husni
  12. 12. Management Options <ul><li>Available options include: </li></ul><ul><li>1.      Nasal and Oral Airways </li></ul><ul><li>2.      Intubating Stylets </li></ul><ul><li>3.      Specialized Stylets </li></ul><ul><li>4.      Airway Exchange Catheters </li></ul><ul><li>5.      Esophageal Airways </li></ul><ul><li>6.      Laryngeal Mask Airways </li></ul><ul><li>7.      Rigid Fiberoptic Laryngoscopes </li></ul><ul><li>8.      Flexible Fiberoptic Bronchoscopes </li></ul><ul><li>9.      Retrograde Intubation </li></ul><ul><li>10. Cricothyrotomy Devices </li></ul><ul><li>11. Transtracheal Jet Ventilation </li></ul>Dr.husni
  13. 13. Nasal and Oral Airways <ul><li>Advantages: Generally allow rapid, easy placement in most patients. </li></ul><ul><li>Disadvantages: Depend on mask ventilation. May not be successful. </li></ul><ul><li>Examples of Use: Adjunct to mask ventilation or other technique of airway management. </li></ul>Dr.husni
  14. 14. Oral and nasel Dr.husni
  15. 15. Intubating Stylets <ul><li>Advantages: Allow intubation of the trachea with minimal visualization of the vocal cords. Technique is easy to learn, and very similar to standard intubation techniques. Generally allows rapid intubation. </li></ul><ul><li>Disadvantages: May be incorrectly inserted into the esophagus. Allow only a blind technique if the larynx is not visible during laryngoscopy. </li></ul><ul><li>Examples of Use: Patient with limited neck range of motion but in whom the posterior larynx and epiglottis can be visualized. </li></ul>Dr.husni
  16. 16. Gum Bougie Dr.husni
  17. 17. Specialized Stylets <ul><li>stylets for use in blind intubations </li></ul><ul><li>Augustine stylet includes an aspiration stylet for detection of esophageal placement. Lighted stylets have a bright light that is used to transilluminate the trachea as a guide to blind intubation. </li></ul><ul><li>Advantages: Do not require visualization of the larynx. Assist intubation by special components. </li></ul><ul><li>Disadvantages: Blind techniques. The endotracheal tube may not pass easily into the larynx. This may occur when the endotracheal tube engages the epiglottis or the glottic cartilaginous structures. </li></ul>Dr.husni
  18. 18. Augustine Guide, Lighted Stylet Dr.husni Examples of Use: Elective management of patient with difficult airway or emergent use if mask ventilation is possible.
  19. 19. Airway Exchange Catheters <ul><li>Airway Exchange Catheters </li></ul>Dr.husni
  20. 20. Esophageal Airways <ul><li>Esophageal Obturator, Combitube </li></ul>Dr.husni Advantages: Easy to place. Do not require laryngoscopy. Disadvantages: Improper placement can obstruct the airway or heighten the risk of aspiration. Will not work in patients with obstruction of the airway at or below the vocal cords. Examples of use: Emergency airway management when endotracheal intubation is not possible because of lack of skilled personnel or possibly because of inability to visualize the airway.
  21. 21. Laryngeal Mask Airways <ul><li>Advantages: Relatively short learning time. Does not require visualization of the larynx. </li></ul><ul><li>Disadvantages: Improper placement of the endotracheal tube may occur. Passage of the endotracheal tube may not be possible when tube engages the glottic structures. </li></ul><ul><li>Examples of Use: Elective intubation of patient with known difficult airway; unsuspected difficult airway if mask ventilation is possible. </li></ul>Dr.husni
  22. 22. Rigid Fiberoptic Laryngoscopes <ul><li>Elective or emergent management of the difficult airway in the asleep patient. </li></ul><ul><li>easier to use and maintain compared to FBI. Less fragile than FBI. </li></ul>Dr.husni Bullard Laryngoscope
  23. 23. Flexible Fiberoptic Bronchoscopic Intubation (FBI) <ul><li>: FBI is useful in managing patients with difficult airways </li></ul>Dr.husni
  24. 24. Difficult Airway Cart Dr.husni
  25. 25. Retrograde Intubation <ul><li>ِِ A wire passed retrograde from a puncture in the cricothyroid membrane to the mouth to allow passage of an endotracheal tube into the trachea. </li></ul><ul><li>Advantages: </li></ul><ul><li>* Ensure passage of the endotracheal tube into the trachea. </li></ul><ul><li>*Does not require visualization of the larynx. </li></ul><ul><li>*May be performed rapidly by skilled practitioner </li></ul><ul><li>Disadvantages: </li></ul><ul><li>*May cause bleeding in the airway. </li></ul><ul><li>*The endotracheal tube may not pass easily </li></ul>Dr.husni
  26. 26. <ul><li>Retrograde Kit </li></ul>Dr.husni
  27. 27. <ul><li>Suggested Contents </li></ul><ul><li>Fiberoptic Scope and Light Source Suction Reservoir Container Yankaur Suction Instrument Suction Tubing Tongue Depressor Tongue Forceps Large Magill Forceps Small Magill Forceps Short Laryngoscope Handle Pediatric Laryngoscope Handle Miller Laryngoscope Blades, Sizes 0-3 MAC Laryngoscope Blades, Sizes 1-4 </li></ul><ul><li>Tape Oral Airways Sizes 00-10 Nasal Airways, 28-34 French Laryngeal Mask Airways, Sizes 1-5 Endotracheal Tubes, 2.5-9.5 mm Stylets, Adult and Pediatric Airway Exchange Catheter Syringes, 5 cc and 10 cc Lubricant Decongestant Spray Lidocaine Ointment Lidocaine 10% Spray Cetacaine Spray IV Catheters 18-14 Gage Sodium Chloride 9% Jet Ventilation Tubing, Connectors, Valve Retrograde Intubation Kit Emergency Cricothyrotomy Kit Oxygen Cylinder, Regulator, Key </li></ul>Dr.husni
  28. 28. Cricothyrotomy Devices <ul><li>: Kits that allow introduction of some type of tube into the trachea via cricothyroidotomy </li></ul><ul><li>Temporary airways only, and need to be replaced by a tracheostomy after establishment of ventilation and stabilization of the patient. </li></ul><ul><li>Advantages: Rapid access to the subglottic trachea. Does not require visualization of the larynx </li></ul><ul><li>Disadvantages: May cause bleeding. It is possible to pass the breathing tube into a fascial plane instead of the trachea. </li></ul>Dr.husni
  29. 29. <ul><li>Examples of Use: Emergency access to the airway. Cricothyroidotomy may be the most appropriate choice in the patient in whom ventilation is not possible by mask. </li></ul><ul><li>Melker, </li></ul><ul><li>Patil, </li></ul><ul><li>Arndt </li></ul>Dr.husni
  30. 30. <ul><li>Contraindications For Use </li></ul><ul><li>Ongoing coagulopathy. </li></ul><ul><li>Obscure cricothyroid anatomy. </li></ul><ul><li>Infection of the cricothyroid membrane. </li></ul><ul><li>Mass (i.e. goiter). </li></ul><ul><li>Potential Complications </li></ul><ul><li>    1.  Bleeding 2. Pneumothorax </li></ul><ul><li>.  3   Pneumomediastinum 4. Cutaneous fistula </li></ul><ul><li>    5. Subcutaneous emphysema 6. Infection </li></ul><ul><li>. 7 Tracheoesophageal fistula 8.  Hematoma </li></ul><ul><li>    9.   Catheter dislodgment </li></ul><ul><li>           </li></ul><ul><li>    </li></ul>Dr.husni
  31. 31. Patil Dr.husni
  32. 32. <ul><li>  </li></ul>Dr.husni Identification of the Cricothyroid Membrane
  33. 33. Dr.husni 4. Make a skin incision with the #15 disposable scalpel large enough to admit the catheter, over the cricothyroid membrane, close to the cricoid cartilage
  34. 34. Dr.husni 5. Cannulate the trachea with the catheter tip facing caudad. A loss of resistance is felt when the trachea is entered.
  35. 35. Dr.husni 6. Aspirate air into a water filled 5 cc syringe to confirm catheter position within the tracheal lumen .
  36. 36. Dr.husni 7. Remove the needle and advance the catheter and dilator caudad. Aspirate again to confirm position. 8. Remove the dilator and aspirate once again to insure correct placement within the trachea. 9. Connect the catheter to oxygen source and secure catheter with the tape provided. Patil, Melker Arndt
  37. 37. Dr.husni Takahata 1997 . The efficacy of the &quot;BURP&quot; maneuver during a difficult laryngoscopy. Anesth Analg 1997 Feb;84(2):419-421. The displacement of the larynx in the three specific directions (a) posteriorly against the cervical vertebrae, (b) superiorly as possible, (c) slightly laterally to the right have been reported and named the &quot;BURP&quot; maneuver