The document discusses the management of difficult airways. It defines difficult mask ventilation and difficult laryngoscopy/intubation. It describes various tests that can be used to assess a difficult airway, such as the Mallampati test, thyromental distance, sternomental distance, and neck mobility tests. Radiographic predictors of a difficult airway are also discussed, along with causes of difficult intubation related to patient anatomy and various medical conditions.

10. CAUSES OF DIFFICULT INTUBATION Pierre Robin Syndrome Micrographia, Macroglossia, Cleft soft palate Treacher Collins Syndrome Auricular & ocular defect, molar & mandibular hypoplasia. Goldenhar’s Syndrome Auricular and ocular defects, molar and mandibular hypoplasia; occipitalization of atlas. Down’s Syndrome Poorly developed or absent bridge of the nose, macroglossia Kilppel-Feil Syndrome Congenital fusion of a variable number of cervical vertebrae; restriction of neck movement.

11. ACQUIRED Infections Supraglottitis Croup Abscess Ludwig’s angina Laryngeal oedema Laryngeal oedema Distortion of the airway and trismus Distortion of the airway and trismus. Arthritis Larynx, Rheumatoid Arthritis Ankylosing spondylitis TMJ ankylosis, cricoarytenoid, deviation of restricted mobility of Cervical spine. Ankylosis of cervical spine, less commonly ankylosis of TMJ; lack of mobility of cervical spine. Tumour Benign Tumor Malignant Tumor Stenosis or distortion of the airway Fixation of larynx to adjacent tissues. Trauma Oedema of airway, unstable#, haematoma Obesity Short thick neck, sleep apnoea Acromegaly Macroglossia, Prognanthism Acute Burns Oedema of airway

13. AIRWAY ANATOMY

14. ANATOMY OF LARYNX

29. Significance- Class B and C: difficult laryngoscopy

32. Grades 3 and 4 : Difficult laryngoscopy Grading of reduction in A.O.Extension Grade I : > 35° Grade II : 22-34° Grade III : 12-21° Grade IV : < 12° Grade Reduction of A.O.Extension 1 none 2 One third 3 Two third 4 complete

37. Palm Print as a Predictor of Difficult Airway in DM

50. MANAGEMENT OF DIFFICULT INTUBATION : Correct position of the patient - A pillow (10 cm) should be placed under the head but not under the shoulders. - Morton and colleagues (1989) defined this position as lower neck flexion 35 o and extension of the plane of face 15 o (both angles relative to horizontal plane)

57. 9. Bullard Laryngoscope : This is a fiber-optic laryngoscope with a built in rigid 90 0 curved blade. It is battery operated Eye piece is attached to the main body of the scope at 45 0 angle. - Useful in mid-facial hypoplasia syndrome and unstable cervical spines.

59. 11. Upsher fibrecoptic laryngoscope – combines fibreoptic round the corner viewing with maneuverability. - The tip of blade is advanced until it comes to rest close to the cords. The tube sits in the semi-enclosed space in the blade. - The variable focus eye piece enables the operator to obtain uninterrupted view of the procedure. The eye piece can be attached to T.V. Camera for teaching purposes.

61. Glidescope L with video intubating system Truview evo2 Laryngoscope

65. Awake Intubation

66. SPECIALIZED TECHNIQUE : 1. Light wand : it has battery handle and copper stylet (about 45 cms) covered in white plastic. As it enters trachea, transilluminated light is seen as bright, circumscribed below cricoid cartilage if it enters esophagus, light is not easily seen. - Once position of light wand is confirmed then the tube is threaded and guided through it.

69. 3. Patils syracuse oral airway- allows fibreoptic intubation 4. Ovassapian fiberoptic intubating airway – Accommodates tracheal tube upto 9 mm diameter. 5. COPA (Cuffed Oropharyngeal airway )- Disposable device that combines a guided airway with an inflatable distal high volume lowpressure cuff and a proximal 15mm adapter. - distal tip should be behind base of tongue

70. 6. Pharyngo-tracheal lumen airway - it is double lumen tube consisting of a long tube with a distal cuff (15 cc) designed to be inflated in esophagus and shorter tube that protrudes through the larger tube and past alarge proximal cuff (100 cc) to ventillate the lungs.

72. LMA classic (standard LMA)

73. LMA PROSEAL & LMA SUPREME

74. - LMA unique (disposable)

76. 11. Pharyngeal airway Xpress – Curved tube with anatomically shaped gilled distal tip, large oropharyngeal cuff and an open hooded window that allows ventilation. More effective seal than LMA. “ Pharyngeal Express” Airway

77. new type of SLA device that does not have a cuff, rather, it has a preformed plastic that fits anatomically to the shape of the pharynx. This device allows one to give positive pressure ventilation to the patient without cuff. This device also contains a chamber (about 50 mls) as storage for regurgitant fluids to collect. 12 .

78. Transtracheal Techniques : - Usually a small IV cannula (14/16) is required. It is advisable to keep this fitted with usual 15 mm connector of 3.5 mm endotracheal tube. - The patients should be positioned to achieve maximum extension of neck. Thyroid and cricoid cartilages are identified and the skin overlying the cricothyroid membrane is fixed. A 14 IV needle is inserted through the membrane into the trachea and directed towards carina. The correct intratracheal position is verified by free aspiration of air through a syringe containing saline. - Begin with 5 psi and increase in increments of 5 psi until adequate chest excursion occurs. - No more than 25 psi and no more than half a second inspiratory time. Emergency tracheostomy : - It is always better to oxygenate the patient via transtracheal I.V. cannula while also performing tracheostomy. - Percutaneous dilatational tracheostomy (PCDT) takes time and is usually not recommended where urgency is there –

80. MINI TRACHEOSTOMY (CONT.)

85. Positioning for morbidly obese patient

86. Whelan - Calicott position

88. Airway management in trauma

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