1. The document discusses the clinical anatomy and evaluation of the difficult adult airway. It describes techniques to assess the airway including measurements of mouth opening, neck mobility, and laryngeal visualization grade.
2. Common causes of difficult airways include anatomical abnormalities, infections, tumors, trauma, and obesity. Assessment indices help predict difficult intubation including the Wilson score, Lemon assessment, and Benumof's 11-parameter analysis.
3. Key airway measurements discussed are thyromental distance, hyomental distance, sternomental distance, inter-incisor gap, atlanto-occipital extension, and Cormack-Lehane grade during direct laryngoscopy. These
This document discusses the identification and management of difficult airways. It notes that maintenance of the airway is the anesthetist's primary responsibility, and 30% of anesthesia-related deaths are due to inability to manage the difficult airway. Key points include:
- Properly identifying patients at risk of a difficult airway through history, physical exam, and airway assessments is critical for optimal patient preparation and equipment selection.
- Various physical exam tests and indices like Mallampati score, thyromental distance, and neck mobility can help predict difficult intubation.
- Multiple techniques and personnel experienced in difficult airway management may be needed to secure the airway when difficulties are encountered. Proper planning can help reduce
The document discusses difficult airway assessment and management. It defines a difficult airway as situations involving difficult mask ventilation, difficult intubation, difficult placement of a supraglottic airway device, or difficult surgical airway access. It describes predictors of a difficult airway related to patient characteristics and anatomy. It also discusses the importance of assessing the airway and having appropriate equipment and personnel prepared when encountering an anticipated or unanticipated difficult airway.
The document discusses the difficult airway, including its definition, causes, assessment, and management. It defines difficult ventilation and difficult intubation. Causes can be related to the anesthesiologist, equipment, or patient factors like congenital syndromes or acquired conditions. Assessment involves history, physical exam including airway indices like Mallampati score, and radiologic evaluation. Management includes preparing a difficult airway cart and having alternate plans for securing the airway.
Airway assessment is important for identifying patients at risk of a difficult airway. Several tests can be used including Mallampati scoring, mouth opening, neck mobility, and thyromental distance. A difficult airway is when facemask ventilation or intubation is not possible using conventional methods. It is important to prepare for difficult airway scenarios by having proper equipment and involving senior help. Identifying difficult airway risks pre-operatively allows time for planning alternative strategies to ensure patient safety.
This document discusses difficult airways and methods for assessing airway difficulty. It begins by defining difficult airway and difficult mask ventilation. It then discusses factors that can predispose patients to difficult airways, such as obesity, beard, missing teeth, snoring, and certain medical conditions.
The document outlines several tests and scoring systems that can be used to assess airway difficulty, including the Mallampatti test, thyromental distance, neck mobility, and inter-incisor distance. It provides details on how to perform and interpret these assessment tests. Finally, it discusses several scoring systems like LEMON, Wilson's criteria, and Benumof's 11 parameters that can help predict difficult laryngoscopy.
This document discusses preoperative airway assessment. It begins by defining the airway and why assessing it is important, as respiratory events are a leading cause of anesthesia-related injuries. It then defines what constitutes a difficult airway and lists various individual predictors and scoring systems that can be used for assessment, including measurements of neck and mouth structures. Overall, thorough preoperative airway examination involving multiple predictive tests can help identify patients that may present difficulties during ventilation or intubation.
Spinal anaesthesia involves injecting local anaesthetic into the cerebrospinal fluid surrounding the spinal cord. A brief history was provided including the discovery of cerebrospinal fluid in the 1700s and the first planned spinal anaesthesia on a human in 1891. Key anatomy was discussed including the levels of the spinal cord and vertebrae. Common local anaesthetics used for spinal anaesthesia like bupivacaine and ropivacaine were listed along with typical dosages. Factors affecting the level of spinal block were summarized.
1. Difficult intubation can result in significant morbidity and mortality, so proper prediction allows time for equipment selection and experienced personnel.
2. Several physical exam findings can predict difficult airways, including reduced neck mobility, short chin-to-hyoid or thyromental distances, large tongue size, and reduced mouth opening.
3. Scoring systems like Mallampati, Wilson, and Cormack-Lehane grading can synthesize exam findings to predict difficult mask ventilation, intubation, or laryngoscopic views. Physical indicators are combined in some group indices to improve predictive power.
This document discusses the identification and management of difficult airways. It notes that maintenance of the airway is the anesthetist's primary responsibility, and 30% of anesthesia-related deaths are due to inability to manage the difficult airway. Key points include:
- Properly identifying patients at risk of a difficult airway through history, physical exam, and airway assessments is critical for optimal patient preparation and equipment selection.
- Various physical exam tests and indices like Mallampati score, thyromental distance, and neck mobility can help predict difficult intubation.
- Multiple techniques and personnel experienced in difficult airway management may be needed to secure the airway when difficulties are encountered. Proper planning can help reduce
The document discusses difficult airway assessment and management. It defines a difficult airway as situations involving difficult mask ventilation, difficult intubation, difficult placement of a supraglottic airway device, or difficult surgical airway access. It describes predictors of a difficult airway related to patient characteristics and anatomy. It also discusses the importance of assessing the airway and having appropriate equipment and personnel prepared when encountering an anticipated or unanticipated difficult airway.
The document discusses the difficult airway, including its definition, causes, assessment, and management. It defines difficult ventilation and difficult intubation. Causes can be related to the anesthesiologist, equipment, or patient factors like congenital syndromes or acquired conditions. Assessment involves history, physical exam including airway indices like Mallampati score, and radiologic evaluation. Management includes preparing a difficult airway cart and having alternate plans for securing the airway.
Airway assessment is important for identifying patients at risk of a difficult airway. Several tests can be used including Mallampati scoring, mouth opening, neck mobility, and thyromental distance. A difficult airway is when facemask ventilation or intubation is not possible using conventional methods. It is important to prepare for difficult airway scenarios by having proper equipment and involving senior help. Identifying difficult airway risks pre-operatively allows time for planning alternative strategies to ensure patient safety.
This document discusses difficult airways and methods for assessing airway difficulty. It begins by defining difficult airway and difficult mask ventilation. It then discusses factors that can predispose patients to difficult airways, such as obesity, beard, missing teeth, snoring, and certain medical conditions.
The document outlines several tests and scoring systems that can be used to assess airway difficulty, including the Mallampatti test, thyromental distance, neck mobility, and inter-incisor distance. It provides details on how to perform and interpret these assessment tests. Finally, it discusses several scoring systems like LEMON, Wilson's criteria, and Benumof's 11 parameters that can help predict difficult laryngoscopy.
This document discusses preoperative airway assessment. It begins by defining the airway and why assessing it is important, as respiratory events are a leading cause of anesthesia-related injuries. It then defines what constitutes a difficult airway and lists various individual predictors and scoring systems that can be used for assessment, including measurements of neck and mouth structures. Overall, thorough preoperative airway examination involving multiple predictive tests can help identify patients that may present difficulties during ventilation or intubation.
Spinal anaesthesia involves injecting local anaesthetic into the cerebrospinal fluid surrounding the spinal cord. A brief history was provided including the discovery of cerebrospinal fluid in the 1700s and the first planned spinal anaesthesia on a human in 1891. Key anatomy was discussed including the levels of the spinal cord and vertebrae. Common local anaesthetics used for spinal anaesthesia like bupivacaine and ropivacaine were listed along with typical dosages. Factors affecting the level of spinal block were summarized.
1. Difficult intubation can result in significant morbidity and mortality, so proper prediction allows time for equipment selection and experienced personnel.
2. Several physical exam findings can predict difficult airways, including reduced neck mobility, short chin-to-hyoid or thyromental distances, large tongue size, and reduced mouth opening.
3. Scoring systems like Mallampati, Wilson, and Cormack-Lehane grading can synthesize exam findings to predict difficult mask ventilation, intubation, or laryngoscopic views. Physical indicators are combined in some group indices to improve predictive power.
Spinal anesthesia involves injecting local anesthetic into the subarachnoid space of the spinal canal. The summary discusses the key points of spinal anesthesia including:
1. The technique involves preparing equipment and positioning the patient before inserting the spinal needle between vertebrae to inject local anesthetic and induce nerve block.
2. Complications include hypotension from sympathetic blockade and post-dural puncture headache from leakage of cerebrospinal fluid through the puncture site in the dura mater.
3. Indications are for lower body and lower abdominal surgeries, with contraindications including infection, coagulopathies, and anatomical abnormalities that prevent safe needle placement.
1) The document discusses the history and techniques of fiberoptic intubation. It began with the first rigid bronchoscopy in 1897 and the development of the flexible fiberoptic bronchoscope in 1966.
2) There are different modes of fiberoptic intubation including anesthetized oral, anesthetized nasal, awake oral, and awake nasal. Proper airway anesthesia and sedation techniques are important to prepare for awake fiberoptic intubation.
3) The document reviews techniques for fiberoptic intubation including how to open the airway, use various airway devices, handle the bronchoscope, advance the scope, and pass the endotracheal tube. It emphasizes the importance of proper setup
Dr. Aftab came upon the scene of a car accident and found the driver was unable to breathe properly. His efforts to clear the driver's airway were not improving the situation. Dr. Aftab remembered an alternative procedure and rushed back to his car. The document then describes different types of cricothyroidotomy procedures, their anatomy, indications, steps, and complications. It returns to the scenario, where Dr. Aftab faces another emergency case he cannot intubate due to mandibular fracture. Seeing the worsening oxygen saturation, Dr. Aftab decides to use an alternative airway procedure.
This document provides an overview of airway assessment. It defines the airway and divides it into upper and lower sections. It discusses the need for airway intervention and importance of assessment. The four pillars of airway management are outlined. Essential components of assessment include history, physical examination, and specific tests. Individual indices like mouth opening and group indices like Wilson scoring are examined to predict difficult mask ventilation, laryngoscopy, and intubation. Radiological indices and specific anomalies affecting the airway are also reviewed.
The tumescent liposuction procedure involves the use of lidocaine (a local anesthetic), epinephrine (a hormone and a neurotransmitter that shrinks blood vessels and minimizes bleeding), and a saline solution that is injected into the treatment area. The fluid causes the fat and skin to swell up, making it easier to suction out excess fatty cells.
Upper airway anatomy includes the mouth, nasal cavity, nasopharynx, oropharynx, larynx, and lower airway including the trachea and bronchi. Factors predisposing to a difficult airway include congenital deformities, infections, tumors, arthritis, and injuries. A thorough airway assessment involves history, physical exam including focused tests like Mallampatti score, thyromental distance, jaw mobility, and neck range of motion to identify potential difficulties and plan management.
The document discusses airway assessment for anesthesia. It defines the upper and lower airways and provides details on relevant anatomy. Key points of airway assessment are identified including patient history, external examination focusing on dentition, head and neck mobility. Specific tests like Mallampati score, thyromental distance and range of motion are described. The document emphasizes the importance of thorough airway assessment prior to procedures to anticipate difficult intubation. Advanced assessment methods involving imaging and fiberoptics are also mentioned.
This document discusses fiberoptic intubation, including:
1. Indications for fiberoptic intubation such as difficult airway cases or cervical spine injuries
2. Topical anesthesia techniques for awake fiberoptic intubation, including nerve blocks to anesthetize the nasal passages, pharynx, and larynx
3. Proper setup and positioning for fiberoptic intubation, including devices to aid visualization and intubation
This document discusses succinylcholine (also known as suxamethonium), a depolarizing neuromuscular blocking agent used in medical procedures requiring short-term muscle paralysis. It describes succinylcholine's mechanism of action as mimicking acetylcholine to initially stimulate nicotinic receptors, followed by desensitization. The document outlines factors that affect succinylcholine's short duration such as its breakdown by plasma cholinesterase and genetic variations in this enzyme. Key indications for succinylcholine include endotracheal intubation and electroconvulsive therapy due to its extremely fast onset and short duration of action.
This document discusses the history, techniques, and physiology of controlled hypotensive anesthesia. It began in 1917 to provide a bloodless surgical field for neurosurgery. Various techniques were developed over time using drugs like nitroprusside and anesthetics to safely lower blood pressure. Key aspects include carefully monitoring vital organ perfusion and using positioning, ventilation, and fluids to potentiate the effects while avoiding dangerous drops in blood flow to the brain, heart, kidneys and other organs.
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.
Airway assessment and pedictors of difficult airway....must know for anaesthe...drriyas03
This document discusses the importance of airway management expertise and outlines factors that can indicate a difficult airway. It notes that respiratory events are the second most common cause of injuries in anesthesia practice. Various anatomical measurements and assessments are described that can help predict a difficult airway, including Mallampati score, thyromental distance, neck mobility, and mandibular range of motion. Radiographic assessments like CT scans can also provide useful information. No single test is perfectly predictive, so anesthesiologists must always be prepared for an unanticipated difficult airway.
1) Ropivacaine is a long-acting local anesthetic that is less lipophilic and less cardiotoxic than bupivacaine.
2) It produces anesthesia via sodium channel blockade and has a slower onset but similar duration of action to bupivacaine at higher concentrations.
3) Ropivacaine causes less motor blockade than bupivacaine and has potential advantages for epidural anesthesia, peripheral nerve blocks, and postoperative pain management due to more rapid recovery of motor function.
Neuraxial anesthesia involves injecting anesthetic medication into the epidural space surrounding the spinal cord or into the cerebrospinal fluid surrounding the spinal cord. This numbs the patient from the abdomen to the toes and can eliminate the need for general anesthesia. There are several types of neuraxial anesthesia including spinal, epidural and caudal blocks. Neuraxial anesthesia provides analgesia with less risk of respiratory depression compared to general anesthesia and limits surgical stress responses. Potential complications include hypotension, neurological issues, and post-dural puncture headache. Careful patient positioning and drug selection can affect the level and density of the resulting nerve block.
Alternative technique of intubation retromolar, retrograde, submental and oth...Dhritiman Chakrabarti
This document discusses alternative airway techniques such as retrograde intubation, submental intubation, and others. It begins by defining difficult airway situations and providing anatomical details of the larynx. It then describes the technique of retrograde intubation, involving passing a wire through a needle in the cricothyroid membrane and using it to guide an endotracheal tube. Indications for retrograde intubation include facial anomalies limiting mouth opening. The technique of submental intubation is also summarized, involving creating a submental skin incision and tunnel to guide the endotracheal tube. Applications of these alternative techniques include maxillofacial, dental, and plastic surgeries.
This document provides an overview of the anatomy of the epidural space. It discusses the boundaries, contents, size, and structures that must be penetrated to access the epidural space. Key points include that the epidural space lies between the spinal meninges and vertebral canal, contains connective tissue, fat, blood vessels and spinal nerves. It varies in size from 1-6mm depending on the spinal region. To access it requires penetrating the skin, ligaments and ligamentum flavum in the midline.
Laryngospasm is a protective reflex that causes glottic closure to prevent aspiration. It can impede respiration if sustained. While rare, it is most commonly seen during emergence from anesthesia. Complete laryngospasm with closure of the vocal cords poses risks like hypoxia, while partial laryngospasm can be treated by removing stimuli, positioning, airway maneuvers, sedation or muscle relaxants. Prevention focuses on identifying at-risk patients and using non-irritating anesthesia to minimize stimuli during intubation and extubation.
This document discusses the importance of airway assessment prior to anesthesia. It defines a difficult airway as one where a trained anesthetist experiences difficulty with mask ventilation, tracheal intubation, or both. Components of airway examination are described, such as mouth opening, neck mobility, and Mallampati score. Predictors of difficult mask ventilation and intubation are provided. Specific tests are outlined to assess the oropharynx, hyomental distance, thyromental distance, and range of neck motion. Causes and prevalence of difficult airways are reviewed. The document emphasizes performing a thorough airway assessment to predict and prepare for potential difficulties.
This document discusses various types of breathing circuits and airway management devices. It describes Mapleson breathing circuit classifications and notes that the Magill and Bain systems are efficient for spontaneous and controlled ventilation, respectively. The Jackson Rees or Type F circuit has a larger reservoir bag, allowing for assisted or controlled ventilation, especially in children. The document also outlines various airway assessment techniques, predictors of difficult intubation/mask ventilation, and management strategies and devices for securing the airway, including oral/nasal airways, face masks, laryngeal mask airways, and tracheal intubation equipment.
Spinal anesthesia involves injecting local anesthetic into the subarachnoid space of the spinal canal. The summary discusses the key points of spinal anesthesia including:
1. The technique involves preparing equipment and positioning the patient before inserting the spinal needle between vertebrae to inject local anesthetic and induce nerve block.
2. Complications include hypotension from sympathetic blockade and post-dural puncture headache from leakage of cerebrospinal fluid through the puncture site in the dura mater.
3. Indications are for lower body and lower abdominal surgeries, with contraindications including infection, coagulopathies, and anatomical abnormalities that prevent safe needle placement.
1) The document discusses the history and techniques of fiberoptic intubation. It began with the first rigid bronchoscopy in 1897 and the development of the flexible fiberoptic bronchoscope in 1966.
2) There are different modes of fiberoptic intubation including anesthetized oral, anesthetized nasal, awake oral, and awake nasal. Proper airway anesthesia and sedation techniques are important to prepare for awake fiberoptic intubation.
3) The document reviews techniques for fiberoptic intubation including how to open the airway, use various airway devices, handle the bronchoscope, advance the scope, and pass the endotracheal tube. It emphasizes the importance of proper setup
Dr. Aftab came upon the scene of a car accident and found the driver was unable to breathe properly. His efforts to clear the driver's airway were not improving the situation. Dr. Aftab remembered an alternative procedure and rushed back to his car. The document then describes different types of cricothyroidotomy procedures, their anatomy, indications, steps, and complications. It returns to the scenario, where Dr. Aftab faces another emergency case he cannot intubate due to mandibular fracture. Seeing the worsening oxygen saturation, Dr. Aftab decides to use an alternative airway procedure.
This document provides an overview of airway assessment. It defines the airway and divides it into upper and lower sections. It discusses the need for airway intervention and importance of assessment. The four pillars of airway management are outlined. Essential components of assessment include history, physical examination, and specific tests. Individual indices like mouth opening and group indices like Wilson scoring are examined to predict difficult mask ventilation, laryngoscopy, and intubation. Radiological indices and specific anomalies affecting the airway are also reviewed.
The tumescent liposuction procedure involves the use of lidocaine (a local anesthetic), epinephrine (a hormone and a neurotransmitter that shrinks blood vessels and minimizes bleeding), and a saline solution that is injected into the treatment area. The fluid causes the fat and skin to swell up, making it easier to suction out excess fatty cells.
Upper airway anatomy includes the mouth, nasal cavity, nasopharynx, oropharynx, larynx, and lower airway including the trachea and bronchi. Factors predisposing to a difficult airway include congenital deformities, infections, tumors, arthritis, and injuries. A thorough airway assessment involves history, physical exam including focused tests like Mallampatti score, thyromental distance, jaw mobility, and neck range of motion to identify potential difficulties and plan management.
The document discusses airway assessment for anesthesia. It defines the upper and lower airways and provides details on relevant anatomy. Key points of airway assessment are identified including patient history, external examination focusing on dentition, head and neck mobility. Specific tests like Mallampati score, thyromental distance and range of motion are described. The document emphasizes the importance of thorough airway assessment prior to procedures to anticipate difficult intubation. Advanced assessment methods involving imaging and fiberoptics are also mentioned.
This document discusses fiberoptic intubation, including:
1. Indications for fiberoptic intubation such as difficult airway cases or cervical spine injuries
2. Topical anesthesia techniques for awake fiberoptic intubation, including nerve blocks to anesthetize the nasal passages, pharynx, and larynx
3. Proper setup and positioning for fiberoptic intubation, including devices to aid visualization and intubation
This document discusses succinylcholine (also known as suxamethonium), a depolarizing neuromuscular blocking agent used in medical procedures requiring short-term muscle paralysis. It describes succinylcholine's mechanism of action as mimicking acetylcholine to initially stimulate nicotinic receptors, followed by desensitization. The document outlines factors that affect succinylcholine's short duration such as its breakdown by plasma cholinesterase and genetic variations in this enzyme. Key indications for succinylcholine include endotracheal intubation and electroconvulsive therapy due to its extremely fast onset and short duration of action.
This document discusses the history, techniques, and physiology of controlled hypotensive anesthesia. It began in 1917 to provide a bloodless surgical field for neurosurgery. Various techniques were developed over time using drugs like nitroprusside and anesthetics to safely lower blood pressure. Key aspects include carefully monitoring vital organ perfusion and using positioning, ventilation, and fluids to potentiate the effects while avoiding dangerous drops in blood flow to the brain, heart, kidneys and other organs.
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.
Airway assessment and pedictors of difficult airway....must know for anaesthe...drriyas03
This document discusses the importance of airway management expertise and outlines factors that can indicate a difficult airway. It notes that respiratory events are the second most common cause of injuries in anesthesia practice. Various anatomical measurements and assessments are described that can help predict a difficult airway, including Mallampati score, thyromental distance, neck mobility, and mandibular range of motion. Radiographic assessments like CT scans can also provide useful information. No single test is perfectly predictive, so anesthesiologists must always be prepared for an unanticipated difficult airway.
1) Ropivacaine is a long-acting local anesthetic that is less lipophilic and less cardiotoxic than bupivacaine.
2) It produces anesthesia via sodium channel blockade and has a slower onset but similar duration of action to bupivacaine at higher concentrations.
3) Ropivacaine causes less motor blockade than bupivacaine and has potential advantages for epidural anesthesia, peripheral nerve blocks, and postoperative pain management due to more rapid recovery of motor function.
Neuraxial anesthesia involves injecting anesthetic medication into the epidural space surrounding the spinal cord or into the cerebrospinal fluid surrounding the spinal cord. This numbs the patient from the abdomen to the toes and can eliminate the need for general anesthesia. There are several types of neuraxial anesthesia including spinal, epidural and caudal blocks. Neuraxial anesthesia provides analgesia with less risk of respiratory depression compared to general anesthesia and limits surgical stress responses. Potential complications include hypotension, neurological issues, and post-dural puncture headache. Careful patient positioning and drug selection can affect the level and density of the resulting nerve block.
Alternative technique of intubation retromolar, retrograde, submental and oth...Dhritiman Chakrabarti
This document discusses alternative airway techniques such as retrograde intubation, submental intubation, and others. It begins by defining difficult airway situations and providing anatomical details of the larynx. It then describes the technique of retrograde intubation, involving passing a wire through a needle in the cricothyroid membrane and using it to guide an endotracheal tube. Indications for retrograde intubation include facial anomalies limiting mouth opening. The technique of submental intubation is also summarized, involving creating a submental skin incision and tunnel to guide the endotracheal tube. Applications of these alternative techniques include maxillofacial, dental, and plastic surgeries.
This document provides an overview of the anatomy of the epidural space. It discusses the boundaries, contents, size, and structures that must be penetrated to access the epidural space. Key points include that the epidural space lies between the spinal meninges and vertebral canal, contains connective tissue, fat, blood vessels and spinal nerves. It varies in size from 1-6mm depending on the spinal region. To access it requires penetrating the skin, ligaments and ligamentum flavum in the midline.
Laryngospasm is a protective reflex that causes glottic closure to prevent aspiration. It can impede respiration if sustained. While rare, it is most commonly seen during emergence from anesthesia. Complete laryngospasm with closure of the vocal cords poses risks like hypoxia, while partial laryngospasm can be treated by removing stimuli, positioning, airway maneuvers, sedation or muscle relaxants. Prevention focuses on identifying at-risk patients and using non-irritating anesthesia to minimize stimuli during intubation and extubation.
This document discusses the importance of airway assessment prior to anesthesia. It defines a difficult airway as one where a trained anesthetist experiences difficulty with mask ventilation, tracheal intubation, or both. Components of airway examination are described, such as mouth opening, neck mobility, and Mallampati score. Predictors of difficult mask ventilation and intubation are provided. Specific tests are outlined to assess the oropharynx, hyomental distance, thyromental distance, and range of neck motion. Causes and prevalence of difficult airways are reviewed. The document emphasizes performing a thorough airway assessment to predict and prepare for potential difficulties.
This document discusses various types of breathing circuits and airway management devices. It describes Mapleson breathing circuit classifications and notes that the Magill and Bain systems are efficient for spontaneous and controlled ventilation, respectively. The Jackson Rees or Type F circuit has a larger reservoir bag, allowing for assisted or controlled ventilation, especially in children. The document also outlines various airway assessment techniques, predictors of difficult intubation/mask ventilation, and management strategies and devices for securing the airway, including oral/nasal airways, face masks, laryngeal mask airways, and tracheal intubation equipment.
The document discusses the assessment of difficult airways. It begins by defining different types of difficult airways including difficult mask ventilation, difficult laryngoscopy, and difficult tracheal intubation. It then discusses various predictive tests that can be used for airway assessment including evaluating neck mobility, mandibular space, mouth opening, and Mallampati score. Specific subgroups that may present challenges like pediatrics, obesity, and certain medical conditions are also covered. The document provides an overview of approaches and considerations for difficult airway assessment.
This document discusses airway assessment techniques for predicting difficult intubation. It describes several tests used during airway examination including mouth opening, jaw protrusion, neck mobility, Mallampati score, thyromental distance, and laryngeal palpation. Limitations of airway tests are noted. Proper airway assessment is important for planning management of potential difficult airway scenarios, but cannot predict all difficulties, so preparation for unanticipated problems is key.
This document reviews techniques for advanced airway assessment. It discusses predicting difficult airways using the LEMOS, MOANS, and DOA mnemonics which evaluate factors like mouth opening, neck mobility, obesity, and obstructions. Grading scales for laryngoscopy views and Mallampati classifications are also covered. The document emphasizes properly assessing airway risks before performing endotracheal intubation to prepare for potential difficulties and have alternative plans.
Airway assessment is important to predict difficult ventilation and intubation. Several physical exam findings and tests can help assess the airway. The passage of air includes the upper airway of the mouth, nose, pharynx and lower airway of the trachea and bronchi. Predictors of difficult mask ventilation include obesity, beards, lack of teeth, age and snoring. Predictors of difficult laryngoscopy include limited range of neck motion, receding chin and large tongue. Specific tests evaluate mouth opening, neck flexibility, jaw movement and spine mobility to help identify potential airway challenges.
This document discusses methods for assessing a patient's airway for difficulty with mask ventilation, laryngoscopy, intubation, and a surgical airway. It describes various physical exam findings and grading scales that can help predict challenges, such as neck circumference, mouth opening, jaw protrusion, Mallampati score, thyromental distance, and laryngoscopic view with intubation. Factors like obesity, beard, lack of teeth, older age, and snoring increase risk. Proper airway assessment is important for anesthesia planning and preparing for potential difficulty.
Airway assessment & Recognition of difficult airwayKhairunnisa Azman
This document discusses airway assessment and recognition of compromised airways. It defines a difficult airway as one where ventilation cannot be maintained or intubation requires multiple attempts. A thorough history and physical exam including tests like Mallampati score help predict difficult airways to prepare appropriate management. Clinical signs of airway compromise include respiratory distress, cyanosis, or loss of protective reflexes. Active interventions may be needed for obstruction, aspiration risk, or respiratory failure. Proper airway assessment and management are important for patient safety during anesthesia.
This document outlines the process and components of an orthodontic diagnosis. It describes collecting personal details, medical history, and chief complaint from the patient. A full examination of the face, jaws, bite, teeth, and gums is conducted, including assessing skeletal relationships, occlusion, tooth alignment and spacing, jaw function, and habits. Clinical findings are compared to normal ranges and used to classify the malocclusion and determine if it has skeletal or dental causes. Cephalometric x-rays may also be analyzed to aid diagnosis. The diagnosis informs orthodontic treatment planning.
The document provides details on examining the extra oral structures including the head, neck, face, lips, lymph nodes, salivary glands, and articulatory system. It describes examining each area visually and through palpation to check for abnormalities. For the articulatory system, it examines the temporomandibular joints range of movement, tenderness, sounds, locking, and dislocation, as well as palpating the muscles of mastication for tenderness.
Preoperative assessment 2 physical exam by kiuko m,en,rn midalidi
This document discusses the importance of preoperative physical examination, with a focus on airway assessment. It outlines key tests to evaluate a patient's airway, including the Mallampati test, mouth opening, neck range of motion, jaw slide, and thyromental distance. Combining these tests allows for predicting easy versus potentially difficult airways, guiding anesthesia planning and ensuring proper resources and assistance are available. Accurately performing a full airway assessment takes less than one minute but provides critical information to manage patient risk and optimize safety.
The 3-3-2 rule is an assessment tool used to predict difficult intubations. It involves measuring 3 fingers between the teeth (inter-incisor distance), 3 fingers from the chin to the hyoid bone, and 2 fingers from the hyoid bone to the thyroid cartilage. Distances less than these measurements indicate a more difficult intubation due to an unfavorable alignment of the oral, pharyngeal, and laryngeal axes. The 3-3-2 rule is most effective when combined with other airway assessment tools like the Mallampati score. It helps clinicians anticipate and plan for difficult intubations to minimize risks.
airway management with assessment and guidelines 1.pptxDrHutia
This document discusses the airway and airway assessment. It defines the components of the airway and describes the larynx in detail. Important functions of the airway are described. The document emphasizes the importance of pre-anesthetic airway assessment to prepare for a potentially difficult airway. It outlines specific tests to evaluate the airway including mouth opening, Mallampati score, neck mobility and mandibular subluxation. Predictors of a difficult mask ventilation, laryngoscopy and intubation are provided. The document also discusses management of a difficult airway according to ASA and AIDAA guidelines.
This document discusses thoracic disc disease, which affects the thoracic spine. Thoracic disc herniations are rare, representing 0.25-0.75% of all disc herniations. The most common symptoms are pain between the shoulder blades and along the intercostal nerves, with the T10 dermatome most commonly affected. Treatment typically begins with rest, anti-inflammatories, and physical therapy, with surgery such as anterior discectomy reserved for cases that do not improve with conservative care. Anterior surgical approaches involve entering through the chest wall between the ribs to access and remove herniated disc material compressing the spinal cord or nerves.
Assessment and management of Airway for BSc Nuursing StudentsAme Mehadi
The document discusses airway assessment. It defines the upper and lower airways and describes components of each. It then defines a difficult airway and lists factors that can make mask ventilation and intubation difficult. The document outlines tools for assessing airway difficulty, including individual indices, group indices with or without scoring, laryngoscopy grading, tests of mandibular space, and advanced radiographic assessments. It emphasizes that a thorough airway assessment is critical for airway management and difficult intubations cannot always be predicted.
The document provides an overview of airway anatomy and management techniques. It describes the anatomy starting from the nose down to the trachea. It then discusses factors that can make the airway difficult and techniques for assessing the airway. It explains various airway management techniques including mask ventilation, use of airways, laryngoscopy, intubation, and alternative techniques like LMA and needle cricothyrotomy.
This document discusses the case of a 63-year-old man presenting with a swelling on the right side of his tongue. On examination, a fungating mass was found involving over half of the tongue. Biopsy revealed well and moderately differentiated squamous cell carcinoma. Treatment would involve a near total glossectomy with neck dissections on both sides and postoperative radiotherapy given the large size and invasion. Reconstruction using a thin forearm or thigh flap would be needed to replace the resected tongue tissue and support swallowing function. Close follow-up is needed due to the high risk of local recurrence within the first two years.
Similar to Surgical management of difficult adult airway by Dr.Ashwin Menon (20)
Mucormycosis is an invasive fungal infection caused by fungi of the Mucoraceae family. It is an opportunistic infection seen predominantly in patients with diabetes, neutropenia, or other immunocompromised states. The rhinocerebral form involves the facial, orbital, paranasal sinus and cerebral regions. Diagnosis involves biopsy and culture. Treatment requires control of risk factors, aggressive surgical debridement of infected tissues, and antifungal therapy typically with amphotericin B. Despite treatment, mucormycosis has a high mortality rate of 50-85%.
This document discusses proptosis and exophthalmos. It defines proptosis as forward displacement of the eye of less than 18mm and exophthalmos as protrusion of more than 18mm. Proptosis can be caused by a decrease in orbital volume or increase in soft tissue volume. Clinical evaluation of proptosis involves inspection of the eyes and skull shape and palpation to check for retrodisplacement of the globe. Common causes of unilateral, bilateral, acute, intermittent and pulsatile proptosis are discussed.
This document provides information on corrosive poisoning, including types, mechanisms of injury, clinical features, investigations, management, and treatment. It discusses three main types of corrosives - acids, alkalis, and oxidants. Alkalis are noted as the most dangerous due to their ability to rapidly cause liquifactive necrosis and injury. Clinical features involve the gastrointestinal tract, respiratory system, eyes and skin. Investigations include endoscopy, imaging, and labs. Management focuses on airway protection, dilution, antibiotics, and monitoring. Long term complications like stricture formation may require repeated dilations.
This document discusses different types of tracheostomy tubes. It begins by outlining the functions of a tracheostomy tube and describes the ideal properties. It then details the parts of a tracheostomy tube and various types including cuffed, uncuffed, fenestrated, sizes for neonates/pediatrics/adults, and tubes with special features. It provides guidance on selecting the appropriate tube based on a patient's needs and anatomy. Tube accessories like speaking valves and occlusion caps are also described.
Pterygopalatine fossa and approaches by Dr.Ashwin MenonDr.Ashwin Menon
The pterygopalatine fossa is a small pyramidal space located between the posterior maxilla and pterygoid processes. It contains the maxillary nerve, pterygopalatine ganglion, vidian nerve and branches of the maxillary artery. The fossa has anterior, posterior, medial, lateral and superior walls. Imaging shows its low density due to contained fat. Conditions involving the fossa include referred otalgia, foramen ovale lesions, and hay fever. Nerve blocks of the maxillary, mandibular and inferior alveolar nerves provide anesthesia to the region. The transantral approach is commonly used to access the fossa during procedures like vidian neurectomy.
1) Tracheostomy is a surgical procedure to create an opening into the trachea through the neck. It allows direct access to the breathing tube and is used when a patient requires long-term ventilation or airway clearance.
2) The procedure involves making an incision through the neck, separating the strap muscles, and opening the trachea between the second and fourth tracheal rings. A tracheostomy tube is then inserted.
3) Complications can include bleeding, tube displacement or obstruction, and long-term issues like stenosis. Proper care is needed to suction and change the tube to prevent complications and allow for recovery.
This document provides an overview of deglutition (swallowing) physiology and esophageal manometry. It describes the three phases of swallowing (oral, pharyngeal, esophageal) and the muscles involved in each phase. It also outlines the neural control of swallowing and the brainstem nuclei involved. Regarding esophageal manometry, it describes the different catheter types, indications for the test, and provides a detailed outline of the components and steps to perform esophageal manometry including identifying high pressure zones and measuring lower esophageal sphincter relaxation.
This document discusses the physiology of phonation, or voice production. It defines phonation as the rapid opening and closing of the vocal cords due to the separation and apposition of the vocal folds, accompanied by breath under lung pressure, which creates vocal sound. It describes the anatomy involved in voice production including the lungs, diaphragm, larynx, throat, mouth and nose. It discusses theories of voice production and covers topics like pitch, volume, quality, vocal registers, vocal disorders, vocal injury, and video stroboscopy.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
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The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
4. CLINICAL ANATOMY
• Depth from skin: 18 mm to 32 mm
• Length: 11 cm
• Levels: C6 to Upper border of T5
• Rings: 16 to 20
• 2nd, 3rd, 4th rings are covered by thyroid isthmus
• Cartilaginous ring C-shaped i.e. incomplete posteriorly.
• The edges of the C are connected by trachealis muscle
which helps in narrowing the tracheal lumen during
coughing-Thus higher velocity of air is generated.
5.
6.
7. Definition
No universally accepted definition of the difficult airway
exists, but in broad terms, difficult airway control may be defined
as problematic ventilation using a face mask, incomplete
laryngoscopic visualization, or as a difficult intubation with
standard airway equipment.
8. The incidence of difficult intubation in the operating room
ranges between 1.15% and 3.80% , with failed attempts in
0.05% to 0.35% of cases.
In the emergency department, difficult intubation occurs
in 3.0% to 5.3% of cases with failure rates ranging from 0.5%
to 1.1%.
9. Hypoxia from the difficult airway is commonly
due to:
1. Excessive number of attempts performed by different
operators unsuccessfully.
2. Subsequent attempts with the same devices.
3. Inadequate oxygenation between attempts.
4. Aspiration of gastric contents during face mask
ventilation.
5. Traumatic oedema of the laryngeal aditus.
10. SIGNS & SYMPTOMS
• Dyspnoea at rest or on exertion.
• Stridor
• Neck swelling
• Voice changes
• Haemoptysis
• Dysphagia
• Odynophagia
• Cough
11. CAUSES OF DIFFICULT AIRWAY
Pierre Robin Syndrome Cleft soft palate, glossoptosis,
retrognathia
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.
12. Pierre Robin Syndrome Treacher Collins Syndrome
Goldenhar’s Syndrome Down’s Syndrome
14. 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.
Tumor 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
15.
16. AIRWAY ASSESSMENT INDICES
1. Individual indices.
2. Group indices - Wilson’s score
- Benumof’s analysis
- Saghei & safavi test
- Lemon assesment
3. Radiological indices.
17.
18. EVALUATION OF MANDIBULAR SPACE
THYROMENTAL DISTANCE (PATIL’S TEST)
• Distance from the tip of thyroid cartilage to the tip of
inside of the mentum.
• Neck fully extended / mouth closed
Significance
• Negative result – the larynx is reasonably anterior to the base
of tongue
>6.5 cm No problem with
laryngoscopy & intubation
6 – 6.5 cm Difficult laryngoscopy but
possible
<6 cm Laryngoscopy may be
impossible
19. HYO MENTAL DISTANCE
• Distance between mentum and hyoid
bone
• Grade I : > 6cm
• Grade II: 4 – 6cm
• Grade III : < 4cm – Impossible
laryngoscopy & Intubation
20. STERNOMENTAL DISTANCE
(SAVVA TEST)
• Distance from the upper border of the manubrium to the
tip of mentum, neck fully extended, mouth closed
• Minimal acceptable value – 12.5 cm
• Single best predictor of difficult laryngoscopy and
intubation ( Has high sensitivity & specificity).
21.
22. CORMACK - LEHANE
(Grading at direct laryngoscopy)
Grade 1: Full exposure of glottis (anterior + posterior
commissure)
Grade 2: Anterior commissure not visualized
Grade 3: Epiglottis only
Grade 4: No glottic structure visible.
23.
24. ASSESSMENT OF TMJ FUNCTION
TM joint exhibits 2 function.
1. Rotation of the condyle in the synovial cavity.
2. Forward displacement of the condyle.
First movement is responsible for 2-3cm mouth opening & the
second is responsible for further 2-3cm mouth opening.
Index finger is placed in front of the tragus & the thumb is
placed in front of the the lower part of the mastoid process.
patient is asked to open his mouth as wide as possible. Index
finger in front of the tragus can be intented in its space and
the thumb can feel the sliding movement of the condyle as the
condyle of the mandible slides forward.
SUBLUXATION OF THE MANDIBLE
25.
26. INTER-INCISOR GAP
• Inter-incisor distance with maximal mouth opening
• Normal value > 5 cm / admits 3 fingers.
Significance :
• Positive results: Easy insertion of a 3 cm deep flange of the
laryngoscope blade
• < 3 cm: difficult laryngoscopy
• < 2 cm: difficult LMA insertion
• Affected by TMJ and upper cervical spine mobility
29. UPPER LIP BITE /CATCH TEST
• Class I: Lower incisors can bite the upper lip above
vermilion line
• Class II: can bite the upper lip below vermilion line
• Class III: cannot bite the upper lip
Significance
• Assessment of mandibular movement and dental architecture
• Less inter observer variability
30. Evaluation of Neck Mobility
Patient is asked to hold the head erect, facing directly to
the front maximal head extension angle traversed
by the occlusal surface of upper teeth( can also
measured by goniometer).
Minimum 35⁰ extension is possible at AOJ in normal
individuals.
31. Grade Reduction of A.O.Extension
1 none
2 One third
3 Two third
4 complete
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°
32. ASSESMENT OF A.O. EXTENSION
• Flexion movement of the cervical spine can be assessed by
asking the patient to touch his manubrium sternii with his
chin. If done, the above maneuver assures a neck flexion of
25- 35 degree. Flexion and the extension movement if within
the normal range ,three axis ( oral,pharyngeal & laryngeal
axis) can be brought into a straight line.
can also be done by asking the patient to look at the floor
and at wall after fully flexing and fixing the neck as shown
33. Warning sign of DELIKAN
Place the index finger of each hand, one underneath the chin and
one under the inferior occipital prominence with the head in
neutral position. The patient is asked to fully extend the head
on neck. If the finger under the chin is seen to be higher than
the other, there would appear to be no difficulty with
intubation. If level of both fingers remains same or the chin
finger remains lower than the other, increased difficulty is
predicted.
34. PALM PRINT & PRAYER SIGN
Palm print sign:
Patient’s fingers and palms painted with blue ink and pressed
firmly against a white paper
• Grade 1- all phalangeal areas visible
• Grade 2- deficient inter phalangeal areas of 4th and 5th digits
• Grade 3- deficient inter phalangeal areas of 2nd to 5th digits
• Grade 4- only tips seen.
Prayer sign:
Limited-mobility joint syndrome (stiff-joint sydrome) 30-40% of
Type I diabetics positive "prayer sign“. TM joint and C-spine (e.g.
atlanto-occipital joint) may be involved
36. PRAYER SIGN
A positive "prayer sign" can be
elicited on examination with the
patient unable to approximate the
palmar surfaces of the phalangeal
joints while pressing their hands
together; this represents cervical spine
immobility and the potential for a
difficult endotracheal intubation.
37. 1. SAGHEI & SAFAVI’S
• Weight
• Tongue protrusion
• Mouth opening
• Upper incisor length
• Mallampati class
• Head extension
Any 3 indices if present -
>80kg
< 3.2cm
<5cm
>1.5cm
>1
<70 degree
Prolonged laryngoscopy
GROUP INDICES
39. L: Look Externally
• Obesity or very small.
• Short Muscular neck
• Large breasts
• Prominent Upper Incisors (Buck Teeth)
• Receding Jaw (Dentures)
• Burns
• Facial Trauma
• Stridor
• Macroglossia
40. E Evaluate the 3-3-2 rule
3 fingers fit in mouth
3 fingers fit from mentum
to hyoid cartilage
2 fingers fit from the floor
of the mouth to the top of
the thyroid cartilage
41.
42. Cormack & Lehane Grading
(Grading at direct laryngoscopy)
Grade 1: Full exposure of glottis (anterior +
posterior commissure)
Grade 2: Anterior commissure not visualized.
Grade 3: Epiglottis only.
Grade 4: No glottic structure visible.
46. Grading of reduction in A.O.Extension
Grade I : > 35°
Grade II : 22-34°
Grade III : 12-21°
Grade IV : < 12°
47. 3. WILSON SCORING SYSTEM
5 factors - Weight, upper cervical spine mobility, jaw
movement, receding mandible, buck teeth
• Each factor: score 0-2
• Total score < 5 – Easy laryngoscopy.
6 to 7 - Moderate difficulty.
> 7 - Severe difficulty.
48. 4. BENUMOF’S 11 PARAMETER ANALYSIS
Parameter
1. Upper inciors length
2. Buck teeth
3. Subluxation
4. Interincisor gap
5. Palate configuration
6. Mallampati class
Minimum acceptable value
<1.5cm
Absent
Yes
>3cm
No arching/narrowness
<2
7. TM distance
8. SMS compliance
9. Neck thickness
10. Length of neck
11. Head /neck mvt
> 5cm
Soft to palpation.
Qualitative ( >33cm DI)
>8cm
Normal range
2 for mandibular space
3 for neck examination.
4-2-2-3 rule
4 for tooth
2 for inside of mouth
49. Rule of 1-2-3
• 1 finger breadth for subluxation of mandible.
• 2 finger breadth for adequacy of mouth opening.
• 3 finger breadth for hyomental distance.
Significant difficulty in 2 or more of these components requires detailed
examination.
• 4 finger breath for thyromental distance
• 5 movements- ability to flex the neck upto the manubrium sterni, extension
at the AOJ, rotation of the head along with right & left movement of the
head to touch the shoulder.
Rule of 1-2-3-4-5
• 3 finger in the interdental space.
• 3 finger between mentum and hyoid bone.
• 3 finger between thyroid cartilage & sternum.
Significant difficulty in 2 or more of these components requires detailed
examination.
Rule of Three’s
50. 1. X-Ray neck (lateral view) :
• Occiput - C1 spinous process
distance< 5mm.
• Increase in posterior mandible
depth > 2.5cm.
• Ratio of effective mandibular
length to its posterior depth
<3.6.
• Tracheal compression.
RADIOGRAPHIC PREDICTORS
51. 2. CT Scan:
• Tumors of floor of mouth, pharynx, larynx
• Cervical spine trauma, inflammation
• Mediastinal mass
3. Helical CT (3D-reconstruction):
• Exact location and degree of airway compression
• Flow volume loop
• Acoustic response measurement
• Ultra sound guided
• CT / MRI
• Flexible bronchoscope
ADVANCED INDICES
53. Types of Surgical Airway Procedures
1. Laryngotomy (cricothyrotomy)
2. Elective Temporary Tracheostomy:
– This is performed as a planned procedure, usually under G/A, as a
temporary stage in patients management
3. Permanent Tracheostomy:
– In an operation involving removal of larynx. Tracheal remnant is
brought to surface as a permanent stoma.
54. 4. Emergency Tracheostomy
– Nowadays there ought to be very few indications for this. On occasion
a patient will be seen first with a large laryngeal tumor and require an
emergency tracheostomy.
– To have to do an emergency tracheostomy in conditions such as acute
epiglottitis, respiratory failure, coma etc is a sign of poor forward
planning in the management of the patient.
– It is to be done under L/A.
5. Micro Laryngeal tube placement for airway management
of tracheal stenosis
6. Percutaneous Tracheostomy
55.
56. 1. Laryngotomy (cricothyrotomy)
“Laryngotomy is opening the airway through the
cricothyroid membrane”
• It is used for acute complete airway obstruction when
endotracheal intubation/ ventilation is not possible.
• The procedure can be accomplished in 15 to 30
seconds.
60. 1. Standard technique
Step 1: Immobilize the larynx and
palpate the cricothyroid
membrane.
Step 2: Incise the skin vertically.
Step 3: Incise the cricothyroid
membrane horizontally.
61. Step 4: Insert the tracheal
hook.
Step 5: Insert the Trousseau
dilator and open it to enlarge
the incision vertically.
62. Step 6: Insert the tracheostomy tube. Step 7: Remove the obturator.
63. Step 8: Insert the inner cannula.
Step 9: Attach the tracheostomy
tube to the mechanical ventilator
or a bag valve device.
64. 2. Rapid four step technique
The rapid four-step technique (RFST) can be done quickly and
requires only a number 20 scalpel, hook, and cuffed tracheostomy
tube. For this technique, stand at the head of the patient in the
same position as when performing endotracheal intubation. Next,
perform the following four steps in sequence:
Step 1: Identify the cricothyroid membrane by palpation.
Step 2: Make a horizontal stab incision through both skin and
cricothyroid membrane with the scalpel. The size of the skin
incision is approximately 1 to 2 cm.
66. Step 3: Prior to removal of the scalpel, the hook is placed and
directed inferiorly. Caudal traction is used to stabilize the larynx.
This marks a significant change from the standard method, in
which the tracheal hook is placed under the thyroid cartilage.
Also in contrast with the Standard technique, this step does not
require an assistant to manage the hook.
Step 4: Insert the tracheostomy tube into the trachea
STEP 3 STEP 4
67. 3. Seldinger technique
Commercial cricothyrotomy kits are available that contain all
essential equipment to perform the Seldinger technique.
As an example, the Cook® Melker kit includes the following:
a. 6 ml Syringe
b. 18 Gauge Needle With Overlying Catheter
c. Guide Wire
d. Tissue Dilator
e. Modified Airway Catheter
f. Tracheostomy Tape.
68.
69. Technique
Step 1: Be certain all equipment is present and functioning. Insert
the dilator into the airway catheter. Palpate the cricothyroid
membrane with the index finger of the non dominant hand while
immobilizing the larynx with the thumb and middle finger.
Step 2: Attach the introducer needle to the syringe, and, if time
permits, fill it with a small amount of saline or water. Apply a
small amount of negative pressure on the syringe and insert the
needle carefully into the cricothyroid membrane at a 45 degree
angle with the needle oriented caudaly.
70.
71. Be careful not to insert it too far as this may damage the posterior
wall of the trachea. Watch for the appearance of bubbles in the
water, or feel for the free flow of air into the syringe, indicating
the needle is in the airway.
Step 3: When bubbles appear, remove the syringe and then
remove the needle, leaving the catheter in place, with its distal tip
in the trachea. Thread the guide wire through the catheter into the
trachea. Remove the catheter, sliding it over the guide wire.
Step 4: Make a 1 to 2 cm incision in the skin at the entrance point
of the guide wire with a number 15 scalpel blade. The
cricothyroid membrane must also be incised at this point.
72.
73. Step 5: Thread the combined tissue dilator-airway catheter over
the guide wire and advance it into the skin incision. Following
the curve of the dilator, advance the dilator-catheter unit through
the subcutaneous soft tissue and into the trachea until the cuff of
the catheter is flush against the skin of the neck. A slight twisting
motion may be needed.
Step 6: Remove the tissue dilator and guide wire as a unit,
leaving the airway catheter in the trachea.
Step 7: Secure the airway catheter to the neck with the 'trach
tape' provided in the kit or other appropriate means.
74.
75. COMPLICATIONS
Emergency surgical cricothyrotomy has a much higher
complication rate than elective cricothyrotomy.
Early complications
• Bleeding.
• Laceration of the thyroid cartilage, cricoid cartilage, or
tracheal rings.
• Perforation of the posterior trachea.
• Unintentional tracheostomy.
• Passage of the tube into an extra tracheal location (ie, false
tract).
• Infection.
76. • Long-term complications include subglottic stenosis
and voice changes.
• Rapid Four Step Technique (RFST) involves cricoid
injury.
77. Tracheostomy
• A tracheotomy is an incision into the trachea (windpipe) that
forms a temporary or permanent opening which is called a
tracheostomy.
• Best performed as an elective procedure under endotracheal
anesthesia, in an adequately equipped operation theatre and
aseptic measures.
• Position:
o Supine position with a sandbag under patient’s shoulders
to give extension of head and prominence to the trachea
and larynx.
o Under local anesthesia a compromised position of
extension will have to be found.
78.
79. • Anaesthesia:
– Endotracheal anaesthesia or
– Local anaesthesia (in
obstructive pathologies)
obtained by injection of skin
and subcutaneous tissues
with Xylocaine 2%
1:200000 adrenaline
solution.
– Drugs which depress resp.
system better avoided.
80. • Incision:
– A Transverse/vertical 5 cm incision 2 cm below the lower
border of cricoid cartilage, through skin, S/C fat and deep
cervical fascia.
– Flaps are raised by undermining with blunt dissection to
expose ant. Jugular veins and infrahyoid muscles.
81. • Separation of Infra hyoid
Muscles:
• The fibrous median raphe
b/w the sternohyoid
muscles is defined and
separated with blunt
dissection
– The sternothyroid muscles
on a deeper plane are
identified and retracted
laterally.
82. • Identification of Thyroid Isthmus:
• Anatomical variations in size and
position of thyroid isthmus should
be expected
• The thyroid isthmus may be small
and not interfere with the approach
but in most patients it is of
sufficient size to need dividing.
• A small horizontal incision is made
in the pre tracheal fascia
• Pull thyroid isthmus up or down or
• Divide the thyroid isthmus b/w
large haemostats and ligate or are
over sewn
83.
84. • Opening of the Trachea:
• Trachea is retracted in an
anterio-superior direction by
a tracheal hook below the
cricoid.
• A transverse incision into
intercartilaginous membrane
below the 2nd or 3rd ring and
converted into a circular
opening.
85. • Insertion & fixation of Tracheostomy
tube:
• The type of tracheosomy tube should
be selected prior to surgery.
• A Soft cuffed tube (ported) will be
needed if anaesthesia is to be
continued or positive pressure
ventilation required or if entry of
secretions and blood into trachea are
to be avoided.
• Position of tube is retained by tapes
passed around the neck and tied to
each other on one side of neck.
86. • Wound Closure and Dressing:
– Wound loosely approximated with
skin sutures and sterile sponge
trachesotomy dressing is done
around the tube.
– There should be sufficient space
remaining around the tube to
minimize the danger of
subcutaneous emphysema.
87.
88. Complication
• Intraoperative Complications
Bleeding and injury to big vessels
Injury to tracheoesophageal wall
Pneumothorax
• Early Complications
Bleeding
Tracheostomy tube obstruction
Tracheostomy tube displacement
Infection
91. Percutaneous Tracheostomy
Percutaneous tracheostomy is a bedside procedure requiring a
small surgical field and avoiding the need for an operating room.
It was popularised in the 1990’s as a minimally invasive
technique requiring only a small skin incision.
Anatomical factors: Laryngeal and tracheal anatomy may vary
widely depending on the patient and his/her age. A larynx situated
in the thoracic inlet (laryngoptosis) makes all kinds of
tracheostomy difficult and one gets critically close to big
mediastinal vessels. In such cases open dissection under direct
surgical vision is required.
92. TECHNIQUE
Percutaneous tracheostomy is similar to using a
Seldinger technique to cannulate veins and arteries.
The trachea is entered percutaneously with a thin needle
through which a guide wire is advanced into the trachea.
A bougie is passed over the guide wire and the tract
between the skin and trachea is dilated until a
tracheostomy tube can be advanced into the trachea.
Unlike with conventional surgical tracheostomy, the
trachea, thyroid gland and vascular structures cannot be
visualised during placement of the tracheostomy or to
achieve haemostasis should bleeding occur.
93.
94. Difficult airway:
The patient must be easy to intubate in the event that alternative
techniques of ventilation by oro- or naso-tracheal intubation is
required should the patient’s airway obstruct following removal
of the endotracheal tube e.g. with in-correct placement of the
percutaneous tracheostomy, accidental decannulation, bleeding
etc.