Dr. Noureldin lecture at ICEM Egypt 2012. ICEM Egypt 2012 is the leading medical conference and exhibition for Intensive Care and Emergency Medicine in Egypt

1. Management of
Difficult Airway
ABDEL H NOURELDIN
PROGRAM DIRECTOR
CHAIRMAN SCIENTIFIC COMMITTEE
EMIRATES SOCIETY OF EMERGENCY MEDICINE
TAWAM HOSPITAL EMERGENCY MEDICINE RESIDENCY PROGRAM
ICEM – DECEMBER -2012

2. SHOW THE VIDEO

3. EMERGENCY AIRWAY HAS TO MANAGED
 PLAN A
 PLAN B
 PLAN Z

4. What do we need for any airway?
Good
Time Oxygen
Saturation
96 t0 99%

6. Figure 1

7. AIRWAY MANAGEMENT
PAST (12 YEARS AGO) Current
 (RSI) was used in 83.6% time  RSI was used 86.2% time
 succinylcholine was used as a  Now it is only 40.5% of the cases
paralytic in 92.0% of the cases, (p<0.01). Rocoronium is used as a
paralytic in 58.6%
 Etomidate is used as an induction
agent 82.5%  Etomidate is used 90.4% (p<0.01).
 direct laryngoscopy (DL) in 98.7% of  DL declined to 57.2% (p<0.01).
the patients. Videolaryngoscopes, accounted for
38.9%
 The failed airway rate: declined  The failed airway rate: 0.2%
from 1.1% (p<0.05).

8. SOURCE OF HIGH FIO2
Dr. Weingart and Levitan -
Annals of Emergency Medicine – March -2012
 None Rebreather  MORE THAN
mask at 15 15L/MINUTES
liter/minute gives CAN DELIVER
you 60% to 70% ABOUT 90% FIO2
FIO2

9. TIME FOR PREOXYGENATION
Dr. Weingart and Levitan -
Annals of Emergency Medicine – March -2012
SICK &
COOPERATIVE UNCOOPERATIVE
PATIENTS
PATIENTS
8 BREATH 3 MINUTES
60 SECONDS

10. PREOXYGENATION
BAILLARD ET ALL-EXAMINED HYPOXIC CRITICALLY ILL
IN ICU
– NIPPV ( none invasive
Standard ventilation
positive pressure ventilation)
 The mean O2 Sat of  The mean O2 Sat of 93%
98% ( 6 patient had to have NIPPV)
 During intubation:  During intubation
desaturated to 93% :desaturated to 81%
 2 patients desaturated  2 patients desaturated
below 80% below 80%

11. A disposable PEEP valve.PEEP settings
from 5 to 20 cm H2O.
If combined with a nasal
cannula set to 15 L/minute, it will
provide CPAP even
without ventilations.

12. PREOXYGENATION
 If you can not get O2 sat to 93% to
95% with high flow O2
 Use NIPPV with pressure less 25 cm
H2O

13. HEAD POSITION
LANE ET AL- ANESTHESIA 2005
20 degree
head up supine
 desaturated desaturated
to 95% in to 95% in
386 seconds 283 seconds
 103 seconds

14. HEAD POSITION
ALTERMATT ET AL- BR.J. ANESTH 2005
Body mass index >35 Body mass index >35
sitting supine
desaturated desaturated
to 90% in to 90% in
214 seconds 162 seconds
52 seconds

15. HEAD POSITION
Dixon ET AL- ANESTHESIA 2005
Body mass index >40 Body mass index >40
25 degree up supine
 showed
similar
benefit

16. HEAD POSITION
RAMKUMAR ET AL- J. ANESTH 2011
20 degree
head up supine
desaturated desaturated
to 95% in to 95% in
452 seconds 364 seconds
88 seconds

19. PASSIVE APNIEC OXYGENATION
 Apneic oxygenation is not a new
concept:
> 100 years old concept:
 Apneic diffusion oxygenation,
 Diffusion respiration
 Mass flow ventilation

20. PASSIVE APNIEC OXYGENATION
 In an apneic patient:
 250 mL/minute of oxygen will
move from the alveoli into the
bloodstream.
 8 to 20 mL/minute of carbon
dioxide moves into the alveoli
during apnea

21. PASSIVE APNIEC OXYGENATION
 In an apneic patient:
 net pressure in the alveoli to become slightly
subatmospheric, generating a mass flow of gas
from pharynx to alveoli.
 PaO2 can be maintained at greater than 100
mm Hg for up to 100 minutes without a single
breath,

22. PASSIVE APNIEC OXYGENATION
TAHA ET AL- ANESTHESIA - 2006
O2 AT 5 L/MINUTE VIA
CONTROL GROUP
NASAL CANULA
NO  DEXATURATI
DESATURA ON TO 95%
TION FOR 6 AT 3.65
MINUTES
MINUTES
AVERAGE

23. PASSIVE APNIEC OXYGENATION
RAMACHANDRAN ET AL- CLIN. J. ANESTHESIA - 2010
OBESE PATIENTS: O2 AT 5 OBESE PATIENTS:
L/MINUTE VIA NASAL CANULA CONTROL GROUP
DESATURATION TO 95 %  DEXATURATION TO 95%
OR MORE FOR 5.29 OR LESS FOR 3.49
MINUTES MINUTES AVERAGE
8 PATIENT HAD O2 SAT. >  I PATIENT HAD O2 SAT >.
95% 95%
MINIMUM SPO2 94.3%  MINIMUM SPO2 %87.7

25. PASSIVE APNIEC OXYGENATION
15 L / min. via nasal
catheter during the
induction and
muscle relaxant

26. Direct laryng. vs video laryng.
MAY – 2012
750 INTUBATION
 1st attempt. Success  1st attempt. Success
rate 84.4% rate 97.3%
Cormack – Lehane grade Cormack – Lehane grade
I & II view 82.8% I & II view 93.6%.

27. ROCURONIUM VS SUCCINYLCHOLINE
ROCURONIUM SUCCINYLCHOLINE
 Time to desaturate to  Time to desaturate to
95% Was 378 seconds 95% Was 242 seconds
 Obese patient time to  Obese patient time to
desaturate to 92% was desaturate to 92% was
329 seconds 283 seconds

28. Sugammadex
Anesth Analg 2007;104:569 –74)
 Sugammadex, 4 mg/kg IV, more rapidly and effectively
reversed residual neuromuscular blockade when
compared with neostigmine (70 g/kg IV) and drophonium
(1 mg/kg IV).
 Use of sugammadex was associated with less frequent dry
mouth than that with the currently used reversal drug
combination

29. ROCURONIUM VS SUCCINYLCHOLINE
 Roc. Dose of 1.2 produced
excellent intubation condition at
40 seconds
 Roc. Can be reverse with
sugmmadex in few seconds
 In difficult intubation it give more
time to intubate the patient .

30. Sugammadex for Rocuronium

32. 25 y/o female with h/o asthma, was
brought by paramedics, combative
pulling her O2 mask off and her O2
sat 85%

33. 35 y/o male who drank chlorax at work accidently,
complain of dyspnea and has strider.
Vital are normal and O2 sat 92% on 100% oxygen

34. Believe in yourself

35. THANK
YOU