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Difficult Intubation
             &
Difficult Airway Trolley
      Rashid M Khan
            Sr. Consultant
        National Trauma Centre
       Muscat, Sultanate of Oman
Objectives of this talk
• Introduction to the difficult airway for the nurse
  assistants.

• How to assess, manage & assist with difficult airway!

• The algorithm and its purpose!

• The difficult airway trolley!

• Understanding of different airway devices!
Airway management is really easy…
      …except when it isn’t…
To Maximize Success…
…recognize and predict difficult airway

…choose appropriate technique and
 equipment

…possess technical skills to assist
 intubation, drugs, and devices
The anesthesia nurses role!


• Should Predict the difficult airway!

• Provide assistance & support!

• Has equipment/drugs ready!

• Has experience to offer!
Predicting the
 Difficult Airway

…if you have time
LEMON Law
Look at patient’s head & neck anatomy

Examine the airway

Mallampati

Obstructions

Neck mobility
Look at Head & Neck Anatomy
• Obesity: rapid desaturation,
  difficult intubation, ventilation
• Facial hair: hides small chin,
  can make bagging difficult /
  impossible
• Large teeth: hide airway,
  obscure tube passage
• Jagged teeth: lacerate
  balloon
Look at Facial Anatomy
Look at Oropharyngeal Anatomy
 • Narrow face, high-arched palate:
   decreased side-to-side diameter

 • Large tongue: hides airway

 • False teeth: help bagging, remove for
   intubation
Examine the Airway
       The 1 – 2 – 3 rule


1. Ability to
invaginate index
finger in front of the
tragus as patient
opens mouth
Examine Airway
• Mouth open: 2 fingers
  – Allows insertion of tube,
    laryngoscope

• Mentum to hyoid: 3 fingers
  – Predicts ability to
    compress tongue into
    submandibular space
Mallampati Score
• With patient seated: extend
  neck  open mouth  stick
  out tongue
• Visualize base of tongue,
  faucial pillars, uvula, pharynx
Mallampati Score
          Difficulty
None     None   Moderate   Severe
Airway Obstructions

 • Foreign body
 • Angioedema?
 • Hematoma?
 • Dentures?
 • Epiglottis?
Neck Mobility Restriction
Prior condition
• Surgery
• Rheumatoid
  arthritis
• Osteoarthritis
• Others
Being Prepared is Good Assistance
     Keep SOAPME Ready:
                •Suction

                •Oxygen

                •Airway

         •Pharmacological agents

                •Monitors

               •Equipment
The Difficult Airway Cart
Difficult Airway Cart
• A shelf and 5 Drawers
• Mobile
• Robust
• Clearly labelled
• Easily cleaned
• Attach DAS
  algorithms
• Restocking list
What should be in the Difficult
          Airway Cart?
•Top Shelf        •Cricothyrotomy Kit, wide bore
                  Intracath 12 or 14 G.
•The Side         •BVM, Jet Ventilator + connector
                  •Bougie
•Draw 1           •LMA
                  •Oral & Nasopharyngeal airways
•Draw 2           •Video-laryngoscopes: Cmac, Truview
                  PCD
•Draw 3           •Regular & alternative laryngoscope
                  blades: Curved & Straight, Mc Coy
                  •ETT
•Draw 4           •Tracheostomy Tubes

•Draw 5           •Intubating LMA, Trachlight, Fiberoptic
                  scope
The Difficult Airway Cart
Always start with Pre-oxygenation
 • Provides oxygen reservoir within
   lungs, blood and body tissues.

 • Allows for several minutes of
   apnea without desaturation.

 • Nitrogen washout.

 • Use NRB, BVM or NIV for 3-5
   mins.
Helping Preoxygenation and
mask ventilation prior to intubation
• Keep appropriate size oral airway or nasal
  trumpet ready.

• Leave dentures.

• In bearded patients, apply water-soluble
  lubricant or opsite to get good seal, especially
  if lots of facial hair
Apneic Oxygenation
• New Concept!

• Involves maintaining
                           Nasal Prongs
  patent upper airway
  passage & oxygenation
  during apneic period.

• Use Nasal prongs @ 15l
  02.
Always start intubation attempts:

• After a good preoxygenation.

• Using technique with which you
  are most experienced and
  comfortable.

• Don’t repeat the same technique
  more than twice, you will not get
  a different result.
Endotracheal intubation
 Basic instruments that you should keep
ready




                                  Magill’s Forceps
 Laryngoscope




                   Styleted ETT
Role of the nurse anesthetist
   during laryngoscopic attempts:
• Providing adequately checked laryngoscope & ETT.

• Providing cricoid pressure, if full stomach.

• Applying BURP maneuver to facilitate laryngeal
  visualization.

• Inflating the cuff and ETT fixation after ascertaining
  correct tracheal intubation.
Failed Tracheal

  Intubation?
Always Keep Plan – B Ready
Moving Beyond Laryngoscopy
1. Laryngeal Mask Airway
Available in 8 sizes: 1, 1.5, 2, 2.5, 3, 4, 5, & 6
Proseal LMA
Available in 8 sizes: 1, 1.5, 2, 2.5, 3, 4, 5, & 6
Usage
Usage
LMA Take-Home Points for Nurses
    • Always test cuff before use

    • Don’t lubricate anterior mask

    • Insert only in comatose patient

    • Keep cuff inflated until patient awake

    • Don’t throw out!! Used 40 – 50 times
2. Combitube®
2. Combitube®
Available in 2 sizes: 37 & 41 French G
No
             .2
        15
           ml




                                     No
                                     .2
                   N o. 1




                            N o. 1
                  100 m l
2. Combitube®
2. Combitube®
• Double lumen tube functions as
  esophageal obturator airway plus standard
  cuffed endotracheal tube

• Insert blindly  90% esophageal

• Inflate proximal balloon: 100 mL

• Inflate distal balloon: 5 –15mL
2. Combitube®
• Seals oropharyngeal and nasopharyngeal
  cavities

• Ventilate through blue port
  – Good breath sounds and no air in stomach 
    continue ventilating
  – No breath sounds and air in stomach  use
    white tube
Indications of LMA, Combitube
• Routine / emergency procedures

• Known / unknown difficult airway

• During resuscitation in profoundly
  unconscious patient with no
  glossopharyngeal or laryngeal reflexes
  when tracheal intubation not possible
Contraindications of LMA, Combitube
    …has limited mouth opening

    …has not fasted, except in emergency

    …has  lung compliance

    …is not profoundly unconscious

    …has oropharyngeal growth, trauma
Always keep Alternative

Intubation Aids at Easy &

   Known Locations
3. Intubating LMA
3. Intubating LMA
Available in 3 sizes, 3, 4 & 5 with dedicated ETTs available in 6 / 6.5 / 7 / 7.5
                                     & 8mm
3. Intubating LMA
4. Flexible Fiberoptic Scope
4. Flexible Fiberoptic Scope
      Advantages
  •   Allows direct airway visualization
  •   Causes little hemodynamic stress
  •   Nasotracheal or orotracheal route
  •   Can be done in all age groups
  •   Requires minimal neck movement
4. Flexible Fiberoptic Scope
 Disadvantages
• Expensive
• Expertise requires practice
• Delicate equipment needs careful
  maintenance
• Visual field easily impaired by blood and
  secretions
4. Flexible Fiberoptic Scope
5. Lightwand (Trachlight)
5. Lightwand (Trachlight)
    Advantages
•   Minimal neck movement
•   Useful adjunct to laryngoscopy
•   Portable and inexpensive
•   Usable in bloody airway
•   Provides definitive airway
5. Lightwand (Trachlight)
    Disadvantages
•   Blind technique
•   May damage airway
•   Usually requires darkened room
•   Expertise requires practice
6. Intubating Stylet (Bougie)
6. Intubating Stylet (Bougie)
• Gum elastic – use as guidewire
    Advantages
•   Aids placement of definitive airway
•   Easy to learn
•   Inexpensive
•   Can be used blindly
6. Intubating Stylet (Bougie)
• Gum elastic – use as guidewire
 Disadvantages
• Expertise requires practice
• Not recommended in “can’t intubate / can’t
  ventilate” scenario
When you fail to secure the

airway and patient is rapidly

       desaturating!!!
7. Transtracheal Jet Ventilation
7. Transtracheal Jet Ventilation
 Advantages
 • Surgical airway of choice if 8 years or
   younger
 • Effective
 • Can serve as temporary airway before
   permanent airway
 • Relatively simple procedure
7. Transtracheal Jet Ventilation
 Disadvantages
 • Significant complications if misplaced
 • Need proper equipment
 • Need high-pressure oxygen
 • Does not protect against aspiration
8. Cricothyrotomy
8. Cricothyrotomy
• Life-saving technique
• Surgical vs. needle / Seldinger vs.
  percutaneous kit
• You must know this procedure before
  starting rapid sequence
8. Cricothyrotomy
• Final common pathways for all cannot
  intubate / cannot ventilate scenarios
• “The hardest part of doing a
  cricothyrotomy is picking up the knife.” –
  Peter Rosen
BURP your patient – grab the larynx
and give…
…Backward
…Upward
…Rightward
…Pressure
And finally…The Algorithm
Conclusions
• Recognize the difficult airway
  – How much time do you have?
  – Who else is around?
  – What is your backup procedure
• Know both old and new methods
• Choose backups based on skills
Thank You
Who is
ready
for this
patient?

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BIOCHEMISTRY-CARBOHYDRATE METABOLISM CHAPTER 2.pptx
BIOCHEMISTRY-CARBOHYDRATE METABOLISM CHAPTER 2.pptxBIOCHEMISTRY-CARBOHYDRATE METABOLISM CHAPTER 2.pptx
BIOCHEMISTRY-CARBOHYDRATE METABOLISM CHAPTER 2.pptx
 

Difficult airway management for nursing staff

  • 1. Difficult Intubation & Difficult Airway Trolley Rashid M Khan Sr. Consultant National Trauma Centre Muscat, Sultanate of Oman
  • 2. Objectives of this talk • Introduction to the difficult airway for the nurse assistants. • How to assess, manage & assist with difficult airway! • The algorithm and its purpose! • The difficult airway trolley! • Understanding of different airway devices!
  • 3. Airway management is really easy… …except when it isn’t…
  • 4. To Maximize Success… …recognize and predict difficult airway …choose appropriate technique and equipment …possess technical skills to assist intubation, drugs, and devices
  • 5. The anesthesia nurses role! • Should Predict the difficult airway! • Provide assistance & support! • Has equipment/drugs ready! • Has experience to offer!
  • 6. Predicting the Difficult Airway …if you have time
  • 7. LEMON Law Look at patient’s head & neck anatomy Examine the airway Mallampati Obstructions Neck mobility
  • 8. Look at Head & Neck Anatomy • Obesity: rapid desaturation, difficult intubation, ventilation • Facial hair: hides small chin, can make bagging difficult / impossible • Large teeth: hide airway, obscure tube passage • Jagged teeth: lacerate balloon
  • 9. Look at Facial Anatomy
  • 10. Look at Oropharyngeal Anatomy • Narrow face, high-arched palate: decreased side-to-side diameter • Large tongue: hides airway • False teeth: help bagging, remove for intubation
  • 11. Examine the Airway The 1 – 2 – 3 rule 1. Ability to invaginate index finger in front of the tragus as patient opens mouth
  • 12. Examine Airway • Mouth open: 2 fingers – Allows insertion of tube, laryngoscope • Mentum to hyoid: 3 fingers – Predicts ability to compress tongue into submandibular space
  • 13. Mallampati Score • With patient seated: extend neck  open mouth  stick out tongue • Visualize base of tongue, faucial pillars, uvula, pharynx
  • 14. Mallampati Score Difficulty None None Moderate Severe
  • 15. Airway Obstructions • Foreign body • Angioedema? • Hematoma? • Dentures? • Epiglottis?
  • 16. Neck Mobility Restriction Prior condition • Surgery • Rheumatoid arthritis • Osteoarthritis • Others
  • 17. Being Prepared is Good Assistance Keep SOAPME Ready: •Suction •Oxygen •Airway •Pharmacological agents •Monitors •Equipment
  • 19. Difficult Airway Cart • A shelf and 5 Drawers • Mobile • Robust • Clearly labelled • Easily cleaned • Attach DAS algorithms • Restocking list
  • 20. What should be in the Difficult Airway Cart? •Top Shelf •Cricothyrotomy Kit, wide bore Intracath 12 or 14 G. •The Side •BVM, Jet Ventilator + connector •Bougie •Draw 1 •LMA •Oral & Nasopharyngeal airways •Draw 2 •Video-laryngoscopes: Cmac, Truview PCD •Draw 3 •Regular & alternative laryngoscope blades: Curved & Straight, Mc Coy •ETT •Draw 4 •Tracheostomy Tubes •Draw 5 •Intubating LMA, Trachlight, Fiberoptic scope
  • 22. Always start with Pre-oxygenation • Provides oxygen reservoir within lungs, blood and body tissues. • Allows for several minutes of apnea without desaturation. • Nitrogen washout. • Use NRB, BVM or NIV for 3-5 mins.
  • 23. Helping Preoxygenation and mask ventilation prior to intubation • Keep appropriate size oral airway or nasal trumpet ready. • Leave dentures. • In bearded patients, apply water-soluble lubricant or opsite to get good seal, especially if lots of facial hair
  • 24. Apneic Oxygenation • New Concept! • Involves maintaining Nasal Prongs patent upper airway passage & oxygenation during apneic period. • Use Nasal prongs @ 15l 02.
  • 25. Always start intubation attempts: • After a good preoxygenation. • Using technique with which you are most experienced and comfortable. • Don’t repeat the same technique more than twice, you will not get a different result.
  • 26. Endotracheal intubation Basic instruments that you should keep ready Magill’s Forceps Laryngoscope Styleted ETT
  • 27. Role of the nurse anesthetist during laryngoscopic attempts: • Providing adequately checked laryngoscope & ETT. • Providing cricoid pressure, if full stomach. • Applying BURP maneuver to facilitate laryngeal visualization. • Inflating the cuff and ETT fixation after ascertaining correct tracheal intubation.
  • 28. Failed Tracheal Intubation?
  • 29. Always Keep Plan – B Ready
  • 31. 1. Laryngeal Mask Airway Available in 8 sizes: 1, 1.5, 2, 2.5, 3, 4, 5, & 6
  • 32. Proseal LMA Available in 8 sizes: 1, 1.5, 2, 2.5, 3, 4, 5, & 6
  • 33. Usage
  • 34. Usage
  • 35. LMA Take-Home Points for Nurses • Always test cuff before use • Don’t lubricate anterior mask • Insert only in comatose patient • Keep cuff inflated until patient awake • Don’t throw out!! Used 40 – 50 times
  • 37. 2. Combitube® Available in 2 sizes: 37 & 41 French G
  • 38. No .2 15 ml No .2 N o. 1 N o. 1 100 m l 2. Combitube®
  • 39. 2. Combitube® • Double lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tube • Insert blindly  90% esophageal • Inflate proximal balloon: 100 mL • Inflate distal balloon: 5 –15mL
  • 40. 2. Combitube® • Seals oropharyngeal and nasopharyngeal cavities • Ventilate through blue port – Good breath sounds and no air in stomach  continue ventilating – No breath sounds and air in stomach  use white tube
  • 41. Indications of LMA, Combitube • Routine / emergency procedures • Known / unknown difficult airway • During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible
  • 42. Contraindications of LMA, Combitube …has limited mouth opening …has not fasted, except in emergency …has  lung compliance …is not profoundly unconscious …has oropharyngeal growth, trauma
  • 43. Always keep Alternative Intubation Aids at Easy & Known Locations
  • 45. 3. Intubating LMA Available in 3 sizes, 3, 4 & 5 with dedicated ETTs available in 6 / 6.5 / 7 / 7.5 & 8mm
  • 48. 4. Flexible Fiberoptic Scope Advantages • Allows direct airway visualization • Causes little hemodynamic stress • Nasotracheal or orotracheal route • Can be done in all age groups • Requires minimal neck movement
  • 49. 4. Flexible Fiberoptic Scope Disadvantages • Expensive • Expertise requires practice • Delicate equipment needs careful maintenance • Visual field easily impaired by blood and secretions
  • 52. 5. Lightwand (Trachlight) Advantages • Minimal neck movement • Useful adjunct to laryngoscopy • Portable and inexpensive • Usable in bloody airway • Provides definitive airway
  • 53. 5. Lightwand (Trachlight) Disadvantages • Blind technique • May damage airway • Usually requires darkened room • Expertise requires practice
  • 55. 6. Intubating Stylet (Bougie) • Gum elastic – use as guidewire Advantages • Aids placement of definitive airway • Easy to learn • Inexpensive • Can be used blindly
  • 56. 6. Intubating Stylet (Bougie) • Gum elastic – use as guidewire Disadvantages • Expertise requires practice • Not recommended in “can’t intubate / can’t ventilate” scenario
  • 57. When you fail to secure the airway and patient is rapidly desaturating!!!
  • 58. 7. Transtracheal Jet Ventilation
  • 59. 7. Transtracheal Jet Ventilation Advantages • Surgical airway of choice if 8 years or younger • Effective • Can serve as temporary airway before permanent airway • Relatively simple procedure
  • 60. 7. Transtracheal Jet Ventilation Disadvantages • Significant complications if misplaced • Need proper equipment • Need high-pressure oxygen • Does not protect against aspiration
  • 62. 8. Cricothyrotomy • Life-saving technique • Surgical vs. needle / Seldinger vs. percutaneous kit • You must know this procedure before starting rapid sequence
  • 63. 8. Cricothyrotomy • Final common pathways for all cannot intubate / cannot ventilate scenarios • “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen
  • 64. BURP your patient – grab the larynx and give… …Backward …Upward …Rightward …Pressure
  • 66. Conclusions • Recognize the difficult airway – How much time do you have? – Who else is around? – What is your backup procedure • Know both old and new methods • Choose backups based on skills
  • 67. Thank You Who is ready for this patient?

Editor's Notes

  1. An adequately stocked Difficult Airway Cart, that can be quickly wheeled in is an absolute must! The dedicated trolley must be mobile, robust ,contain everything you may need to manage various difficult airway situations and it must be capable of facilitating fibreoptic bronchoscopy. Also, don’t forget it needs to pass the standards of Infection Control Manager!!