This document discusses airway management in a case of massive hemoptysis. It outlines the patient's history and examination findings, initial emergency management including fluid resuscitation and blood products, and subsequent deterioration requiring intubation. The document reviews airway assessment tools like the Mallampati score and LEMON criteria. Rapid sequence induction is described as the method of intubation, though initial attempts failed before successful intubation on the second try. Brief cardiac arrest occurred post-intubation but return of spontaneous circulation was achieved with flushing of the endotracheal tube. Key learning points include thorough pre-intubation airway assessment and being prepared to troubleshoot potential post-intubation issues.

1. Airway Management
Anupam Ghimire
GP-EM Resident

2. Objectives
• Case scenario
• Airway management
• Challenges in difficult airway management

3. Case scenario
• 70 yr/F
- COPD , HTN and Post TB fibrosis of Lung
• Coughing up of blood for 2 hrs
- Around 750 ml , fresh red
- Similar episode 1 day back ~ 50 ml

4. • No history of :
- Fever
- Chest pain
- Weight loss, anorexia
- Rashes , bleeding from other sites
- Antiplatelet or Anticoagulant
• Former Smoker

5. Examination
• Anxious , alert , short stature and obese
• Pallor +, ILCCOD-
• Vitals :
Bp : 80/40 mmhg Pulse : 120 bpm
RR: 20 breath/min Spo2: 91 % on RA
T: Afebrile

6. • Chest examination
- Air entry – decreased in lt side
- Vesicular Breath sound
- Conducted sound over lt lung field
• Other system examinations grossly normal

7. Emergency Management
- Airway
- Breathing
- Circulation
- Position: Lt lateral decubitus
- Fluid resustication
- Drugs : Tranxemic acid , Ondansetron
- Blood arranged and cross-matched

8. After 10 min
• Hemoptysis continues  next 250 ml
• Drowsy , Sweating
• MAP : 60 , P: 136-140/min
Spo2 : 88% on 10 L Oxygen
ECG : Sinus Tachycardia
WHAT NEXT ….

9. • Discussion on airway management strategy
• Equipments : Oxygen
- Mask - Monitoring
- Airway ( Oral and nasal ) - Emergency Drugs
- Laryngoscope - Suction
- Endotracheal tube - Self inflating bag
valve resusticator

10. • Airway assessment:
– L- Look externally ( No facial trauma, large incisors,
large tongue)
– E- Evaluate the 3-3-2 rule
• Incisor opening distance: 2 fingerbreadths
• Hyoid-mental distance: 2 fingerbreadths
• Thyroid-to-mouth distance: 1 fingerbreadths
– M- Mallampati score 4
– O- Obstruction: No epiglottitis, peritonsillar abscess,
or trauma
– N- Neck mobility ( neck mobility)

11. • Preoxygenation , Positioning
• Sedative agent :
- Ketamine 50 mg
• Immediately followed by Muscle relaxant
- Succinylcholine 50 mg

12. • Intubation field not seen despite suctioning
• Intubation with size 7 ET tube done  failed
- Cormack Lehane grade 4
• Second attempt done with Preloaded stylet
- Glottic exposure : BURP manaeuver
- Rt lung intubation done , confirmed
- Tube fixed at 28 cm, secured
- Kept in lateral decubitis position

13. • Post intubation sedation given, Bag and mask
ventillation continued
• Spo2 – 97 % with 10 L oxygen
• BP : 110/80 mmhg
• Pulse : 100/ min
• Urine output : 300 ml , clear

14. After 10 min
• Spo2: 34 % on 15 L oxygen
• Bp : ??
• HR: 38 bpm , decreasing
• Pulse : not palpable
What NEXT……

15. • CPR Started, ET tube suctioning done in between
• Injection Adrenaline every 5 min ( 3 doses )
• Injection Atropine 1ml ( 2doses )
• Noradrenaline started
• NO Improvement
What NEXT…..

16. • Flushing of ET tube done
- NS 10 ml
• After 2 minute
- Sp02 : 98% on 10 L oxygen, P: 92 bpm
- ROSC , CPR stopped
- Post resustication care done
- Referred to CTVS center

17. Learning points
• Airway assessment :
– L- Look externally (facial trauma, large incisors, beard,
large tongue)
– E- Evaluate the 3-3-2 rule
• Incisor opening distance: 3 fingerbreadths
• Hyoid-mental distance: 3 fingerbreadths
• Thyroid-to-mouth distance: 2 fingerbreadths
– M- Mallampati score ≥3
– O- Obstruction: Presence of condition such as
epiglottitis, peritonsillar abscess, or trauma
– N- Neck mobility (limited neck mobility)

18. Mallampati Score

20. Rapid Sequence Induction (RSI)
• Sequential administration of an induction
agent and neuromuscular blocking agent to
facilitate endotracheal intubation
• The goal of RSI- facilitate rapid insertion of the
ETT while minimizing physiologic
perturbations

21. RSI Steps
• Discuss airway management strategy with the team
• Set up IV access, cardiac monitor, oximetry, and
capnography/capnometry
• Plan procedure. Assess physiologic status and airway
difficulty.
• Prepare equipment, suction, and potential rescue devices
• Preoxygenate
• Consider pretreatment agents
• Give sedative agent immediately followed by neuromuscular
blocking agent.
• Intubate trachea
• Confirm tube placement.
• Secure tube
• Adjust mechanical ventilation and provide postintubation
sedation.

22. RSI
• Pre treatment agents- Lidocaine, Fentanyl
• Induction agents- Etomidate, Propofol,
Ketamine
• Neuromuscular Blocking- Rocuronium,
Vecuronium, Succinylcholine

23. PEA causes:
• M: massive pulmonary embolism
• A: acidosis
• D: drug overdose
• H: HYPOXIA/hypothermia
• H: hypovolemia
• H: hypokalemia/hyperkalemia
• C: cardiac tamponade
• A: acute MI
• T: tension pneumothorax

24. Troubleshooters: Post intubation
• D - Displacement of tube or cuff
– Auscultate / look etco2
• O - Obstruction of tube/circuit
– Use suction catheter to remove mucus/blood, or
make sure patient not biting down, look for kink in
tube
• P - Pneumothorax
– Verify via USG , CXR, or Needle
thoracocenthesis (high suspicion)
• E - Equipment failure
– ReConnect to Bag mask ventillator

25. Summary
• Anticipation of difficult airway
• Single lung ventillation
• Emergency intubation : RSI
• Troubleshooters of postintubation should be
promptly managed

26. THANK YOU