Information about airways management

1. Dr. OSAMA M. AL_QADHAB M.D
ANESTHOLOGIEST & ICU
4/30/2024 1

2. 4/30/2024 2
• Causes of difficult intubation
• Basic airway evaluation
• Management plan for Anticipated difficult airway – Plan A, Plan
B , Plan C & Plan D
• Gallery of tools
• The Expected & Unexpected Difficult Airway
OBJECTIVES

3. DEFINITION
American society of Anesthesiologist (ASA) suggested
(difficult to ventilate)
 That when sign of inadequate ventilation could not be
reversed by mask ventilation
or
oxygen saturation could not be maintained above 90%

4. DEFINITION
(difficult to intubate)
 If a trained Anaesthetist using conventional
laryngoscope takes more than 3 attempts
or
more than 10 minute to complete tracheal intubation

5. 15- 50%
ARE ONLY PICKED UP

6. 15%
DIFFICULT INTUBATION

7. EXTREMELY
DIFFICULT
ABANDON
GS – 1 in 2000
OBG- 1 in 300

8. CAUSES OF
DIFFICULT INTUBATION
Anesthetist
Pre-op assessment
Equipments
Experience not
enough
Poor technique
Malfunctioning
equipment
Inexperienced assistance

9. CAUSES OF
DIFFICULT INTUBATION
Patient
1. Congenital causes
2. Acquired causes

10. Basic airway evaluation in all
patients
 Dr. Binnion’s LEMON Law
 BONES
 The 4 D’s

11. Dr. Binnions Lemon Law: An easy
way to remember multiple tests…
 L ook externally.
 E valuate the 3-3-2 rule.
 M allampati.
 O bstruction?
 N eck mobility.

12. L: Look Externally
Receding
jaw
Short
muscular neck
Obesity
Buck teeth
Dentures

13. L: Look Externally
Facial trauma
Stridor
Macroglossia

14. E:Evaluate the 3-3-2 rule
14
 3 fingers fit in mouth- Inter incisor distance
 3 fingers fit from mentum
to hyoid cartilage
 2 fingers fit from the floor
of the mouth to the top of
the thyroid cartilage

15. M: Mallampati classification
Class-I Class-II
Class-III Class-IV
soft palate, fauces;
uvula, anterior and
the posterior pillars.
the soft palate, fauces
and uvula
soft palate and base of uvula
Only hard palate

16. O: Obstruction?
 Blood
 Vomitus
 Teeth
 Epiglottis
 Dentures
Tumors
 Impacted Objects

17. N:Neck mobility -Measurement of
Atlanto-Occipital Angle

18. Thyro- Mental Distance
18
Measure from upper edge of thyroid cartilage to chin with the head
fully extended.
• A short thyromental distance = an anterior larynx .
• >7 cm is usually = easy intubation
• < 6 cm = difficult airway

19. MANAGEMENT PLAN
OF
ANTICIPATED
DIFFICULT AIRWAY
4/30/2024 19

20. Is mask ventilation going to be
difficult?
Can’t ventilate
Defined by “BONES”
• Beard
• Obesity
• No teeth
• Elderly
• Snoring

21. Is laryngeal visualization going to
be difficult?
Can’t intubate
Defined by 4 D’s
1. Disproportion
2. Distortion
3. Dysmobility
4. Dentition

22. Disproportion
Pierre robin
sequence
Acromegaly
Prognathism
Achondroplasia

23. Neurofibromatosis
Burns contracture
Distortion
Cystic hygroma

24. Dysmobility
TM joint Ankylosis
Klippel Fiel

25. Edentulous
Buck teeth
Dentition

26. Is cricothyroidotomy going to be
difficult?
Can’t Rescue
 Should assessment reveal a potentially difficult airway
the cricothyroid membrane should be identified and
marked, BEFORE an intervention is undertaken

27. Possible Options!
Following airway assessment, the person performing the
intubation should be in a position to decide between
three possible options
1. Awake intubation
2. Quick look
3. Induction and paralysis

28. 1. Awake Intubation
The patient needs to be intubated awake
There is significant risk of complications if sedatives
and/or muscle relaxants are administered prior to
airway control.

29. 2. Quick Look
The patient may be sedated for an attempt at direct
laryngoscopy WITHOUT muscle relaxation
(“Quick Look”)
There is some risk of failed laryngoscopy
but
There should be a low risk of failed mask ventilation.

30. 3. Induction & Paralysis
The patient may be induced and paralyzed,
In this case the patient is assessed as having a low risk
of laryngoscopy and/or mask ventilation

31. Pre-oxygenation: How Much Is
Enough?
Two techniques common in use:
1. Tidal volume breathing (TVB) of oxygen for 3–5
min
2. Deep breaths (DB) 4 times within 0.5 min
Both are equally effective in increasing arterial
oxygen tension (Pao2).
Anesth Analg 1981; 60: 313–5

32. Each subject received 5 mg/kg thiopental and 1 mg/kg succinylcholine.
Anesthesiology 2001, 95: 754-759
Pre-oxygenation

33. What are we going to do if we
don’t get the Tube?
 Plans “A”, “B” ,“C” and plan “D”.
 Know this answer before you tube.

35. Failure -Why does it happens?
 No critical discussion with colleagues about proposed
management plan
 No request for experienced help
 Exaggerated idea of personal ability
 Ill-conceived plan A and/or plan B
 Poorly executed plan A and/or plan B
 Persisting with plan A too long, starting the rescue
plan too late
 Not involving, and preparing, surgical colleagues

36. GALLERY OF TOOLS
 ILMA
 Video laryngoscopes
 Malleable video stillet- Levitan scope
 Fibreoptic bronchoscope

40. ANTICIPATED DIFFICULT AIRWAY
ELECTIVE EMERGENCY

41. ANTICIPATED DIFFICULT AIRWAY
ELECTIVE EMERGENCY
ANTICIPATED DIFFICULT
AIRWAY

42. Old case of Hemi-mandibulectomy with forehead
flap with trismus for block dissection of neck nodes
ELECTIVE

43. Anesthesia of choice - G.A.
Intubating technique of
choice
?

45. MANAGEMENT PLAN
OF
UNANTICIPATED
DIFFICULT AIRWAY
4/30/2024 45

46. TheUnexpected DifficultAirway
 Experienced help may not be immediately available
 Special equipment may not be immediately
available
 A general anaesthetic has usually been
administered
 A long acting relaxant may have been given
 Backup airway management plans may be poorly
thought out
46

47. Take home message
 Be familiar with the alternative methods of intubating
technique and use it regularly in your day today
practice e.g. ILMA, FOB, Videolaryngoscopes,
cricothyroidotomy…………….
 So that you won’t fumble at the time of crisis
4/30/2024 47

48. GOOD LUCK
4/30/2024 48
Challenges may
be
Waiting for you

49. The whole world is made up of mistakes and
people
Forgive the mistakes and love the people
Thank you