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Difficult Airway.pptx
- 1. DIFFICULT AIRWAY Guide :Dr.Akila MD DA , Assistant professor
- 2. Clinical situation inwhich a conventionally trained Anaesthesiologist experience difficulty with face mask ventilation of upper airway or tracheal intubation or both. •Assessment •Formulation of a plan = Algorithm Guidelines: •ASA •DAS •AIDAA •Canadian Airway focus group
- 3. Not absolute standardof care but as a guide to decision making Importance of prior airway assessment & Anaesthetic records Formulation of prior strategy Significance of oxygenation Adequate neuromuscular blockade prior to declaring failed BMV Call for help early Strategy for extubation Common to all algorithms
- 4. 6 problem • Difficultywith patient cooperation / consent • Difficulty with mask ventilation • Difficulty with SGA placement • Difficulty with laryngoscopy • Difficulty with intubation • Difficulty with surgical airway access
- 5. Difficult Mask ventilation • Mainly •Inadequateseal •Inadequate patency
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- 7. LANGERON Inability for theunassisted anesthesiologist to maintain oxygen saturation >92% using 100% oxygen and positive-pressure mask ventilation Important gas flow leak by the face mask Need to increase gas flow to >15 L/min and to use the oxygen flush valve more than twice No perceptible chest movement Need to perform a two-handed mask ventilation technique Change of operator required.
- 8. 1.Airway manouevre • Triplemanouevre • Assessment • Head extension • Mandibular advancement
- 9. Methods to overcome •Provide upper airway patency • Manipulate • Mandible • Cervical spine • Hyoid bone • Stretch soft pharyngeal tissues
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- 12. Adequacy Subjective • Cyclical condensation •Bag compliance • Chest expansion • Auscultation • Desaturation Objective • Tidal volume • Acceptable airway pressure • Capnogram with a plateau
- 13. One hand FMV Positioning • Sniffing •Ramp Grip • E-C • Chin lift grip
- 15. Prediction Excessive airway obstruction Technical difficultyCategories Others • Male • ↑weight/NC • Snorer • ↑Age • Edentulous • MMC III / IV • Mandibular protrusion test • Cervical spine pathology • Beard • ↓TMD • Edentulous • ↑NC • Radiation / burns • Obesity • Pregnancy • Full stomach • Fixed cervical spine • Operator specific • Inadequate device • Difficult access
- 16. BONES • Beard • Obese •No teeth • Elderly • Snorer MOANS • Mask seal factors • Obese or obstruction • Age extremes • No teeth • Snorer/Stiff lung
- 17. Management • Adjunct • Twohand technique – E-V • Two person four hand approach • Early recourse to SGA or intubation
- 19. Objective method Lim andNielsen • A-Effective • B-Adequate • C-Inadequate • E-Ineffective
- 20. Difficult SGA placement •Inability tointroduce or properly place SGA even after 3 attempts •Change device or size
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- 29. •Inability to visualiseany part of larynx by experienced Anaesthesiologist using conventional method even after 3 attempts or >10mins •Grade 3 or 4 view on laryngoscopy Difficult laryngoscopy
- 30. Difficultlaryngoscopy •Predictors: •LEMON •Look externally •Evaluate 3-3-2rule •Interincisor distance 3 fingers •Hyomental distance 3 fingers •Thyroid to floor of mouth 2 fingers •Mallampati score •Obstruction / obesity •Neck mobility
- 32. Key elements • Correctpositioning • Correct insertion and manipulation of the blade • Optimal • Sternal notch and external auditory meatus in same horizontal plane
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- 35. Anterior Posterior Middle • reducedvolume (e.g. short mandible or short thyromental distance • reduced compliance of soft tissues (e.g. haematoma, infection, mass or previous radiotherapy to submandibular tissues) making compression more difficult • ankylosing spondylitis • manual in-line neck stabilisation • obesity, especially patients with enlarged • dorsocervical fat pads • laryngeal tumours • lingual tonsillar hypertrophy COLUMNS
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- 37. BOUGIE STYLET OPTICALSTYLET EXTERNAL LARYNGEAL MANIPULATION
- 39. Best performance • Optimalsniff position, • Good complete muscle relaxation, • Firm forward traction on the laryngoscope, • Firm external laryngeal manipulation
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- 41. Difficult front of neck access •BANG •Bleeding tendency •Agitatedpatient •Neck scarring / flexion deformity •Growth / vascular abnormality in region of surgical airway
- 42. Mouth opening Factors • Massetermuscle spasm, • TMJ dysfunction, • Burn scar contractures • Progressive systemic sclerosis. TMJ 2 movements - Hinge like & gliding •Interincisor distance 3 cms or 2 finger breadth
- 43. Dentition Prominent maxillary incisors Higherthan original position More posterior laryngopharyngeal position DL
- 44. Tongue • During laryngoscopytongue pushed into mandibular space • Large tongue / Small mandible -DI • Lifiting force ——> Translation of mandible —-> anterior displacement • Upper lip bite test • TMD = >6cm or three finger breadth & <6cm = DI
- 46. Thyromental distance • Sizeof mandible • 6 cms Or 3 fingers • MMC +TMD = good accuracy • NC/TMD >5
- 47. Sternomental distance • 12.5cms •Better sensitivity and specificity
- 48. Neck mobility • Sniffing morningair position • Flattens the primary and secondary curve • Accurate= goniometer • NC >43 cms
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- 50. Diabetes •Prayer sign •Palmprint test •SENS - 13 -75% SPEC- 69 - 96% •Poor predictive value Ankylosing spondylitis •Fusion & rigidity of joints •Cervical fractures & Spinal nerve root compression TMJ disorders •Articular disorders /Non articular disorders •Symptoms- clicking, periauricular pain, radiating pain, pain with chewing, restricted movement.
- 53. OBESITY • LARGECHEEKS • SHORT IMMOBILE NECK • LARGE TONGUE • PHARYNGEAL ADIPOSE TISSUES • LOW FRC • DI = NC >43CMS • NC : TMD >5 • DIFFICULT FM/LARYNGOSCOPY OSA • STOP-BANG quessionaire • Difficult or even impossible mask ventilation Pregnancy ↓FRC
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- 55. Preoxygenation • Techniques • Tidal-volumebreathing technique • Vital capacity breathing
- 56. References • HAGBERG ANDBENUMOF’S AIRWAY MANAGEMENT, 4TH EDITION • Core Topics in Airway Management 3rd Edition – TIM COOK
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Editor's Notes
- #9 Airway manoeuvres are blind techniques used to provide upper airway patency by manipulating solid anatomical structures – the mandible, cervical spine and hyoid bone To stretch soft pharyngeal tissues connected to them – the soft palate, tongue, epiglottis and lateral pharyngeal wall Both techniques generate chin elevation, positioning the mandibular teeth in front of the maxillary, and increase the distance between chin and sternum, resulting in upper airway stretching. Additionally, it increases the distance between chin and cervical spine, resulting in upper airway enlargement
- #10 Inability to generate a measurable airway manoeuvre may signal the need for an airway adjunct before the ventilation attempt.
- #11 Bite block opens mouth Oral ventilation by bypassing nasal and velopharyngeal obstruction Curved portion supports the tongue. Insertion of the wrong size oropharyngeal airway or in light planes of anaes- thesia may lead to iatrogenic airway obstruction, laryngospasm or regurgitation.
- #12 Nasal obstruction and bypassing soft palate and base-of-tongue obstruction. Potential complications are nasal bleeding, trauma and air- way obstruction.
- #13 4-5ml/kg <20-25cmH2O
- #15 ‘E-C’ grip applies an asymmetrical seal on a symmetrical face mask with suboptimal results when applied with a large mask, large patient or by a practitioner with small hands. The generic E-C grip generates both an imperfect seal as the C does not control the whole dome and a suboptimal airway manoeuvre as the E cannot generate and maintain maximal extension of the cervical spine or subluxation of the temporomandibular joints. An imperfect seal forces the practitioner to push the mask on the chin or to use head straps, flexing the neck, compromising the airway manoeuvre and inducing iatrogenic airway obstruction. Chin lift grip is a power grip with the web space between the thumb and index finger against the connector. It is implemented with a new asymmetrical face mask or a symmetrical generic mask with the hook ring removed. The grip controls the whole dome, fingers three, four and five reach for the chin generating and optimised torque for head extension in the sagittal plane
- #16 Mandibular protrusion test 16.2 ± 3.2 mm
- #22 Restricted mouth opening (<2cm) Obstructed upper airway Disrupted upper airway = trauma / burns Stiff lungs
- #23 Silicone construction, reusable. High airway and oesophageal seal. Large drain tube. Extensive evidence base
- #24 First cuffless second generation SGA. Single use. Very easy insertion and low rate of sore throat. Moderate airway seal and low oesophageal seal. Effective conduit for intubation. Widespread use for CPR and out of hospital
- #25 The Combitube comprises two tubes akin to two tracheal tubes of different lengths joined together, with distal and proximal cuffs. If the longer (tracheo-oesophageal) tube enters the glottis, the distal tube is inflated and the device is used as a tracheal tube. If the distal tube enters the oesophagus (it does 98% of time) the upper cuff is inflated in the pharynx and ventilation occurs through holes at the end of the shorter (pharyngeal) tube. Previously popular in out-of-hospital use, especially in North America. Now largely superseded. Cost, high rates of trauma and possibility of ‘failing dangerous’ generally preclude from use in anaesthetic practice. The Easytube is a very similar, but more recently introduced devic
- #26 PVC construction. A development of the laryngeal tube with a second (posterior) tube running parallel to the airway tube to act as a drain tube. Reusable and single-use versions.
- #30 Top: Cormack-Lehane grading system. Grade 1 is visualization of the entire laryngeal aperture; grade 2A is partial visualization of the vocal cords; grade 2B is visualization of only the posterior commissure of the vocal cords or arytenoid cartilages; grade 3A is visualization of only the epiglottis (epiglottis can be lifted); grade 3B is visualization of only the epiglottis (epiglottis cannot be lifted off the posterior pharynx); and grade 4 is visualization of only the soft palate. Bottom: Cook grading system. Easy, the laryngeal inlet is visible; Restricted, the posterior glottic structures are visible and the epiglottis can be lifted; Difficult, the epiglottis cannot be lifted or no laryngeal structures are visible.
- #31 Short neck Beard Facial trauma Tumor
- #33 small child with a small head-ring under the head, in a large child and adult with a single pillow in the obese patient with ‘ramping’ (i) lift the epiglottis anteriorly by pressure on the hyoepiglottic ligament, (ii) displace the submandibular tissues anteriorly and (iii) push the tongue laterally
- #36 Ability to displace the anterior column with a laryngoscope blade narrowing and/or distortion of the upper airway cervical spine mobility is reduced and impact the ability or not to achieve the ‘sniffing position’
- #37 McCoy levering laryngoscope blade, in its flexed position, applies pressure at the base of the tongue lifting the epiglottis anteriorly and is therefore appropriate when there is a posterior column problem (e.g. manual in-line stabilisation of head and neck) where the mandible and submandibular tissues are normal. In contrast when there is an anterior column problem (a mismatch of submandibular space and tissue compressibility) the Miller straight blade may succeed as its low profile produces a higher pressure on the submandibular tissues with the same force (pressure = force/area) and it can be used to lift the epiglottis directly.
- #45 1 lower incisors can bite upper lip above vermilion border 2lower incisors can bite upper lip below vermilion border 3 cannot bite upper lip
- #46 class I—soft palate, fauces, uvula, pillars; class II—soft palate, fauces, uvula; class III—soft palate, base of uvula; class IV—soft palate not visible.
- #51 If the atlanto-occipital joint or laryngeal joints become involved, then neck extension and laryngeal mobility may become limited, making laryngoscopy or intubation difficult. Collagen glycosylation starts in the fourth and fifth interphalangeal joints, preventing the patient from approximating the palms and fingers of the hands; therefore limited phalangeal extension may be used as a predictor of DA management caused by neck and larynx stiffness. The prayer sign and palm print test have been suggested as tests of phalangeal joint immobility.
- #56 Tidal-volume breathing technique. Provide 100% oxygen via a tight-fitting face mask and ask the patient to breathe at normal tidal volumes for three or more minutes. Provide 100% oxygen via a tight-fitting face mask and ask the patient to take eight deep vital capacity breaths in 60 seconds