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Physiologically difficult airway
1) The document discusses physiologically difficult airways which are ones where patient physiology makes intubation high risk rather than anatomical issues. Common risks are hypotension, hypoxemia, and right ventricular failure. 2) Strategies are presented for managing airways complicated by issues like brain injury, cardiovascular problems, respiratory disease, liver or kidney failure, sepsis, and more. 3) The document recommends techniques like rapid sequence intubation, awake intubation, double setup approaches, and having specialized equipment and drugs available to manage difficult airways. Optimizing patient physiology is key to reducing risks of intubation.
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Physiologically difficult airway
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- 2. Introduction • “Difficult airwayis the clinical situation in which conventionally trained anaesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both” the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2013; 118:XX–XX • Fourth NAP of the royal college of anaesthetists and the DAS reported that 61% of airway-related events in ICU were associated with death or permanent neurological damage compared with 14% in operating room • British Journal of Anaesthesia, 117 (S1): i60–i68 (2016)
- 3. • Hypoxemia • Hypotension •Right Ventricular Failure Anatomically difficult airway Physiologically difficult airway One in which obtaining a glottic view or passing an endotracheal tube is challenging One in which physiologic derangements place the patient at higher risk of cardiovascular collapse with intubation and conversion to positive pressure ventilation Introduction
- 4. Hypotension 1.Positive pressure ventilation 2.Rapidadm of IV Fluid 3.Vasopresors 4. Reduced dose induction agents Hypoxemia 1. V/Q mismatch 2. BVM and NIV 3. RSI or DSI 4. THRIVE Rt Ventricular Failure 1.Echo 2. Inc Afterload with PPV 3.Rt Coronary Phys Difficult Airway
- 5. Ahmed and AzimJournal of Intensive Care (2018) 6
- 6. Difficult airway dueto Neurophysiologic Derangement • Traumatic brain injury and stroke patients (raised intracranial pressure) • IBP monitoring • Premedication with fentanyl/remifentanil • Fasciculations caused by succinylcholine can cause rise ICP • Ketamine is no more considered contraindicated • Propofol or Thiopentone
- 7. Physical Head Neutral HeadUp No Compression on IJV Maintain normal intra thoracic pressure Avoid airway obstruction, straining, coughing Pharmacological Premedication –Fentanyl 2mcg/kg RSI-Ketamine and Midaz or Keta – Propofol Muscle relaxant-Rocuronium (Pref) Hemodynamic and Metabolic targets MAPs 90 to 100 mm Hg PaO2- 80 to 100 mm Hg PaCO2- 30-35 mm Hg pH – 7.35-7.45 Normothermia Normoglycemia Adequate sedation/Analgesia Potential Vasodilators should not be used Vasopressin,CCB,NTG,Nitropruside For Acute rise in ICP Hyperventilate (PaCO2 25-30 mm Hg) Hypertonic saline or Mannitol Deepen sedation (boluses of midaz)
- 8. Difficult Airway DueTo Cardiovascular Derangement • Preload, afterload, heart rate and contractility optimization • Screening bedside ECHO • Cardiac tamponade -intubation should be delayed till definitive management of cardiac tamponade is achieved.
- 9. • LVH -avoidof atrial arrhythmias, hypotension and myocardial ischemia • Regurgitant–maintain slightly higher heart rate, low afterload, adequate preload and support contractility • MS –Prevention of increase in PA pressure, HR and marked afterload reduction. • Etomidate & rapid onset Opioids Difficult Airway Due To Cardiovascular Derangement
- 10. Difficult airway dueto Respiratory derangement • Pre-oxygenation- NIV • Bed Side ECHO • Right ventricular function deteriorates with increased intra-thoracic pressure caused by PPV • Inhaled pulmonary vasodilators like nitric oxide or epoprostenol • Correction of HPV- oxygen supplementation
- 11. Difficult Airway DueTo Hepatic Derangement • Raised ICP due to hepatic encephalopathy • Intubated with neuroprotective strategy. • Coagulopathy and are frequently thrombocytopenic • Nasal intubation should not be used
- 12. Difficult Airway DueTo Renal Derangement • Severe metabolic acidosis • Avoid succinylcholine (Hyperkalaemia) • Rocuronium is the drug of choice • Vasopressor should be connected prior intubation • Soda bicarbonate infusion -pH < 7.2 before induction.
- 13. Difficult airway dueto Gut dysfunction • Paralytic ileus, ascites, pseudo-obstruction and raised intra-abdominal pressure • Vomiting and aspiration • Fluid shifts - hypotension during induction
- 14. Difficult airway dueto sepsis • Distributive shock, lactic acidosis and coagulopathy • Volume resuscitation and vasopressor • Invasive hemodynamic monitoring - high-dose noradrenaline • Etomidate & Ketamine
- 15. RSI • Optimal positioningof the patient • Preoxygenation • Inducing agent ( Ketamaine) • Adjunct opioid • Application of cricoid pressure (10 N /30 N ) • Muscle relaxant (succinylcholine/rocuronium) • Maximising first pass
- 16. DIFFICULT AIRWAY CART EQUIPMENT 1.LMA,Oral & Nasopharyngeal airway 2. BVM, Jet ventilator+ connector, Bougie 3. Regular and alternate laryngoscope, blades, curved and straight ,Mc Coy, ETT 4. Intubating LMA, Trachlight ,Fibreoptic scope 5. Cricothyrotomy kit, wide bore intracath, tracheostomy tubes DRUGS 1. Metoclopramide,Ranitidine 2. Opiods –Fentanyl 3. Induction Agents – Ketamine,Etomidate,Propofol, Thiopentone 4. Muscle Relaxant- Sch , Rocuronium 5. Mephentermine, Phenylephrine 6. Adrenaline, Atropine,Dopamine, Nor Adr
- 17. DSI • Agitated patients •Small doses of ketamine or benzodiazepine • Pre-oxygenation • Dexmedetomidine (alpha 2 antagonist) is an alternative in patients in patients who are tachycardiac or hypertensive
- 18. Awake intubation • Topicalizationof the airway • Premedication (Antisialogogues, H2 blocker and metoclopramide) • Flexible scope intubation, video laryngoscopy, light wand, direct laryngoscopy, blind intubation, etc. • Inadequate blunting of airway reflexes -laryngospasm, tachycardia, hypertension, etc.
- 19. Double Setup Approach •Two approaches simultaneously in patients with anticipated failed intubation • Cricothyroid membrane may be identified via ultrasound or clinically before inducing the patient for RSII • Double setup approach increases the safety margin and helps overcome cognitive failure in emergency situation
- 20. Conclusion • Intubation strategy-modification as per the physiological derangement. • Though RSI is the core strategy -modification like awake intubation with videolaryngoscope or flexiblescope intubation and delayed sequence intubation • Preoxygenation and apnoeic oxygenation via NIV and high-flow nasal cannula. • Choice of inducing agent and muscle relaxant
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