DIFFICULT AIRWAY
MANAGEMENT
Tools and Tactics for Success
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First Case of the Day
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ASA Definition
The Difficult Airwayis defined as the clinical situation in which a
conventionally trained Anesthesiologist experiences
difficulty with facemask ventilation of the upper airway,
difficulty with tracheal intubation, or both
Difficult to Ventilateis when signs of inadequate ventilation could not be
reversed by mask ventilation or oxygen saturation could
not be maintained above 90%
Difficult to Intubateis when a trained Anesthetist using conventional
laryngoscope take’s more than 3 attempts
DISCUSSION
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Degrees of Airway Difficulty
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Overlap
Difficult
Mask
Ventilation
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Overlap
Difficult Mask
Ventilation
Difficult
SGA
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Triple Failure
Difficult
Mask
Ventilation
Difficult
Intubation
Difficult
SGA
DANGER ZONE
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An Emergent Surgical Airway is Not
Always Assured
Difficult
Mask
Ventilation
Difficult
surgical
airway
Difficult
Intubation
Danger Zone
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4th National Audit Project NAP4
• Sept 2008-Sept 2009
estimated 2,900,000
GA performed in the
UK
• Data collected on
114,904 GA’s from 309
hospitals over a 2
week period
• 184 serious airway
complications,
including:
-Death (14)
-Brain Damage
-Emergent Surgical
Airway
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NAP4 Lessons Learned
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NAP4 Lessons Learned
Poor Airway Assessment & Poor
Planning contributed to Poor
Outcomes
1. Failure to match strategy to
assessment (technique)
2. Failure to have prepared strategy
(plan B and C)
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NAP4 Lessons Learned
Emergency
Percutaneous
Cricothyrotomy
failed 60% of
the time
13
NAP4 Lessons Learned
A common theme was “failure to plan for
failure”
•In some cases when airway management
was unexpectedly difficult the response was
unstructured. In these cases outcomes
were generally poor.
•The project identified numerous cases
where awake fiber-optic intubation was
indicated but not used
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NAP4 Lessons Learned
• Aspiration was the single most common
cause of death in anesthesia events
• Importantly most aspirations occur due to
failure to recognize risk factors and failure
to adjust the anesthetic technique
accordingly
• Aspiration remains the most frequent
cause of airway related deaths during
anesthesia.
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NAP4 Lessons Learned
One third of the events occurred during
emergence or in recovery. Obstruction was
the common cause in these events
Recommendations:
• Nasal Trumpets
• Oral Airway
• Airway exchange catheter
• SGA prior to removal of ETT (Bailey Maneuver)
• Awaken patient with SGA in place
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Predictors of Difficult Mask Ventilation
• Beard
• OSA
• Obesity
• Male Gender
• Mallampati class III or IV
• Neck Circumference
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Predictors of Difficult
Intubation
• Inadequate Preoperative Assessment.
• History of difficult intubation
• Inadequate equipment
• Experience not enough.
• Poor technique.
• Increased Age
• Mallampati III or IV
Anatomical Factors Affecting
Laryngoscopy
•
Neck Circumference (Single Major Predictor in Obese)
•
Short Neck.
•
Protruding incisor teeth.
•
Long high arched palate.
•
Increase in either anterior depth or Posterior depth of the
mandible decrease in Atlanto Occipital distance
•
Limited cervical range of motion
•
Small mouth opening
•
Temporomandibular joint pathology
Basic Airway Evaluation in All
Patients
• Previous anesthetic problems
• General appearance of the neck, face,
•
•
•
•
•
maxilla and mandible
Jaw movements
Head extension and movements
The teeth and oropharynx
The soft tissues of the neck
Recent chest and cervical spine x-rays
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Think L-E-M-O-N When Assessing a
Difficult Airway
Look externally.
Evaluate the 3-3-2 rule.
Mallampati.
Obstruction?
Neck mobility.
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 (Lg Tongue)
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
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E-Evaluate the 3-3-2 Rule
4/8/2015
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M- Mallampati classification
Class-I
soft palate, fauces;
Uvula, pillars.
Class-III
soft palate and base of uvula
Class-II
the soft palate, fauces
and uvula
Class-IV
Only hard palate
Mallampati ?
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Cormack & Lehane Grading
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O-Obstruction
Blood
Vomit
Teeth
Dentures
Epiglottis
Tumors
Foreign Body (piercings)
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N-Neck mobility -Measurement of
Atlanto-Occipital Angle
Atlanto-Occipital Angle
Estimates the angle
traversed by the
occluded surface of
the upper teeth
Grade I --- > 35°
Grade II –- 22-34°
Grade III – 12-21°
Grade IV -- < 12°
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Thyromental Distance
• Measure from upper edge of thyroid cartilage
to chin with the head fully extended.
• A short thyromental distance equates with an
anterior larynx
• Greater than 7 cm is usually a sign of an easy
intubation
• Less than 6 cm is an indicator of a difficult
airway
• Relatively unreliable test unless combined
with other tests
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Thyromental Distance
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MANAGEMENT PLAN OF ANTICEPATED
DIFFICULT AIRWAY
1.
Discussion with colleagues in advance
2.
Equipment tested before
3.
Senior help backup
4.
Definite initial plan (A) for ventilation and intubation
5.
Definite plan (B) than option of awake intubation
6.
Ideal situation surgery team standby
Preoxygenation
Two Techniques Common in Use:
1.
Tidal volume breathing (TVB) of 100% oxygen via
a tight-fitting face mask for 5 minutes (Preferred
Method)
2.
Deep breaths/Vital Capacity 4 times within 0.5
min (Time to desaturation is consistently shorter
then preferred method)
Why Preoxygenate?
• O2 Consumption Vo2=250ml/min and 2500ml O2 in
FRC (after preO2) = 10 minutes to use this O2
Airway Management A-B-C
Start with Plan A
If plan A fails-
Go to plan B
If plan B fails-
Go to plan C
Plan “A”: (ALTERNATE)
• Different Length of blade
• Different Type of Blade
• Different Position
• Different Equipment
Plan “B”: (BVM and BLIND
INTUBATION Techniques )
• Mask Ventilation
• Bougie
• Combi-Tube?
• LMA an Option?
• Fiberoptic?
Plan-C Can’t Intubate.. Can’t
Ventilate
• Needle Cricothyrotomy
• Transtracheal Jet Ventilation
• Retrograde Wire Intubation
Failure.. Why does it happen
• No critical discussion with colleagues
about proposed management plan
• No request for experienced help
• Exaggerated idea of personal ability
• Ill-conceived plan A and/or plan B
• Poorly executed plan A and/or plan B
• Persisting with plan A too long, starting
the rescue plan too late
• Not involving, and preparing, surgical
colleagues
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GALLERY
OF
TOOLS
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Rigid Laryngoscope Blades Of Alternate
Design And Size
Macintosh
Mc Coy
Magill
Miller
Polio
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Video Laryngoscopy
Airtraq
McGrath
C-Mac
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Video Laryngoscopy
• VL Calls on a
Alternative Skill Set
• In Critical Situations
Unpracticed
Techniques may not
be Helpful
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Video Laryngoscopy
• Use a stylet and shape
it to match your VL
Blade
• Watch the patient not
the monitor when
• inserting the VL Blade
• Trouble passing tube
-Withdraw
-Lift Less
-Drop your angle
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Video Laryngoscopy Versus
Direct Laryngoscopy
• Improved Glottic
View
• Experienced vs
Inexperienced
• Cost
• Standard of the
future?
• Picture Confirmation?
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Bullard Rigid Fiberoptic
Laryngoscope
• Time
• Experience
• Limited Maneuverability
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Stylet Devices
Optical Stylet
• No Nasal Intubation
• No Suction
• Limited to above Cords
Lighted Stylet
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GUM ELASTIC BOUGIE (GEB)
– First used in England
– Cheap
– Good in patients in whom
only epiglottis is visualized
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Supraglottic Airways SGA
Combitube
LMA
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The EsophagealTracheal Combitube
•Useful as emergency
airway
•Two lumens allow
function whether place in
esophagus or trachea
•Esophageal balloon
minimizes aspiration
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Laryngeal Mask Airway
VARIATIONS OF LMA
• LMA – Classic (standard)
• LMA – Flexible (reinforced)
• LMA – Unique (disposable LMA)
• LMA – Fastrach (intubating LMA)
• LMA – C-Trach (Visualization/Intubation)
• LMA – Proseal (gastric LMA)
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LMA – Fastrach (Intubating LMA)
•
Rigid, anatomically curved, airway
tube that is wide enough to accept
an 8.0 mm cuffed ETT and is short
enough to ensure passage of the
ETT cuff beyond the vocal cords
•
Rigid handle to facilitate onehanded insertion, removal
•
Epiglottic elevating bar in the
mask aperture which elevates the
epiglottis as the ETT is passed
through
•
Available in three sizes, one size
for children, two sizes for adults
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LMA C-Trach
• Ventilation
• Visualization
• Intubation
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LMA-Proseal
• High seal pressure - up to
30 cm H20 - Providing a
tighter seal against the
glottic opening with no
increase in mucosal
pressure
• Provides more airway
security
• Enables use of PPV in
those cases where it may
be required
• A built-in drain tube
designed to channel fluid
away and permit gastric
access for patients with
GERD
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LMA-Proseal
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Fiberoptic Aided Intubation
• Most Versatile Tool
Available for Difficult
Intubation
• Optical Elements are
Small
• Visualization Below the
Cords
• Awake Intubation
• Unique Skillset
• Lens Contamination
• Cost
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Can’t Ventilate/Cant Intubate
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Cricothyrotomy
• Airway established
through the
Cricothyroid
Membrane
• Not a Tracheostomy
• Large Bore Catheter
• Expected skill of the
Anesthetist
• Contraindicated in
Neonates and Children
under age 6
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Transtracheal Jet Ventilation
• Maxillofacial, Pharyngeal, or
Laryngeal Trauma,
Pathology or Deformity
• 16-Gauge or Larger (16gtidal volume 400-700)
• 15-30 psi with Insufflation 11.5 sec.
• Specialized systems
capable of using Lowpressure O2
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Retrograde Intubation
• Local Anesthesia of the airway, skin wheel at
puncture site.
• Cricothyrotomy performed with air aspiration
• Retrograde wire is advanced until it emerges
from the mouth. (Magill Forceps)
• Wire is Clamped/Secured at the entry site
• ETT advanced over the wire (Many Techniques)
• Wire removed leaving ETT in place
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Retrograde Intubation
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Extubation of the Difficult Airway
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Airway Exchange Catheter
Extubation in a controlled
manner with a AEC
• Well tolerated
• Airway can be
reintubated
• Can deliver Oxygen
• Provides an avenue for
suction
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Airway Exchange Catheter
• Localize the airway through existing ETT
• Mark AEC at required depth (tube depth
+3 CM)
• Insert AEC and remove ETT
• Tape AEC in place
• Assess for removal of AEC
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Bailey Maneuver
Exchange of ETT for a
LMA
Decreased Severity of
• Cough
• Maximum change
SBP
• Maximum change
HR
• Sore throat
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Bailey Maneuver
• Patient is Deep
• Oral-pharyngeal
suction
• Deflated LMA placed
behind ETT
• LMA cuff inflated
• ETT cuff deflated and
removed
• LMA used for
ventilation
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What's New in the ASA Difficult
Airway Algorithm
2003
2013
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What's New in the ASA Difficult Airway Algorithm
Assess Likelihood and Impact section.
Added:
Difficult Supraglottic airway placement
Separated: Intubation and Laryngoscopy
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What's New in the ASA Difficult Airway Algorithm
2003
2013
Basic Management Choices:
Video-assisted Laryngoscopy as
initial approach to Intubation
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What's New in the ASA Difficult Airway Algorithm
2003
2013
“LMA” changed to “SGA”
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What's New in the ASA Difficult Airway Algorithm
2003
2013
Video-Assisted Laryngoscopy: Listed first
under Alternative Difficult Intubation
Approach
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What's New in the ASA Difficult Airway Algorithm
2003
2013
Under Invasive Airway
Access: Percutaneous airway
techniques and jet ventilation
remain but are
de-emphasized
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Two For The Road
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Two For The Road
• Be familiar with alternative intubating
techniques and use them on a
regular basis in your day to day
practice.
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Two For The Road
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Questions?
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Questions?
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