Difficult tracheal intubation
Dr Tuan Pham Duc
06/2010
Plan
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Preintubation checklist.
Intubation kit .
RSI ( Rapid sequence intubation )
Predicting difficult tracheal intubation
Bougie ( Eschmann stylet ) .
Laryngeal mask airway-Fastrach ( Intubating
LMA)
Cricothyroidotomy
Alternatives intubation techniques
Confirmation of ETT placement .
Miscellaneous
Summary
Preintubation checklist
Intubation kit
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Laryngoscope
ET
Stylet
Syringe 10ml
Suction catheter
Carbon dioxide detector
Oral & nasal airways
Ambu bag & mask attached to oxygen
source
Rapid sequence intubation
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Endotracheal intubation using RSI is
the cornerstone of emergency airway
management .
RSI: the administration of a potent
induction agent followed immediately
by a rapidly neuromuscular blocking
agent to induce unconsciousness &
motor paralysis for tracheal
intubation
RSI
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3 phases: pretreatment-inductionparalysis.
Pretreatment : LOAD Lidocaine Opiod
analgesics Atropine Defasciculating
agents
Pretreatment medications
Induction medications
Paralytic medications
Predicting difficult tracheal
intubation
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LEMON rule
1.
2.
3.
4.
5.
Look externally
E Evaluate the 3-3-2 rule
Mallampati scale
Obstruction present ?
Neck mobility
Difficult airway assessement
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Look externally : physical features
such as a small mandible , large
tongue , short bull neck & obesity ,
facial or mandibular fracture are all
red flags for a difficult airway
Difficult airway assessement
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Mallampati classification
Difficult airway assessement
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Obstruction : 3 signs of upper airway
obstruction are stridor , muffled
voice,difficulty swallowing secretions.
Neck mobility:cervical spine
immobilization in trauma , medical
condition such as ankylosing
spondylitis or RA.
McCormack & Lehane grade
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Bougie ( Eschmann stylet )
Bougie ( Eschmann stylet )
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It can be beneficial in the following
situations :
1. Grade 3 view
2. Poor grade 2 view
3. As a general intubation aid
A bougie can be used on the 1st
attempt intubation when DL has failed
to yield an adequate view
LMA
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A laryngeal mask airway
LMA
Fastrach( Intubating LMA)
Intubating LMA sizes
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1 (<5kg)
1,5 (10-20kg )
2,4 ( 20-50kg )
3,5 ( 50-70kg )
4,5 ( 70-100kg )
Cricothyroidotomy
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Insertion of a tracheal tube through
an incision in the cricothyroid
membrane .
Alternatives intubation techniques
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Glottiscope ( Airtraq..)
Special laryngoscopes
Lighted stylet intubation
Fiberoptic techniques.
Esophageal-tracheal Combitube
Retrograde intubation
Airtraq
Combitube
Confirmation of ETT placement
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Chest auscultation: bilateral breath
sounds
Detection of CO2 exhaled.
Chest Xray :
- Capnography
B-C CO2 color change indicator
A
Miscellanous
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Cricoid pressure:Sellick’s maneuver
External Laryngeal Manipulation or
BURP Backward Upward Right
Pressure maneuver
1. ELM improved the laryngoscopic view
by one whole grade in most pts
initially rated 2 or 3
2. All pts presenting grade 3 view were
converted to grade 1 or 2 with ELM
Summary
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Always be prepared for a difficult
airway.
No single airway assessment tool is
sufficiently sensitive nor specific to
reliably predict or rule out a difficult
airway.
In many cases features of the
patient’s morphology & pathology
enable prediction of a difficult airway