MANAGEMENT OF DIFFICULT AIRWAY

Ravikumar Tripuraneni, MD
Chairman, Dept of Anesthesiology

Shasta Regional Medical Center Redding, CA USA

email: ravi@tripuraneni.com

1971 - 1977

1982 - Present

Redding , California

Difficult Airway
Difficult to mask ventilation of upper airway Difficult to endotracheal intubation Difficulty with patient cooperation and consent Difficulty with tracheostomy

Closed Claims Analysis in USA

179 Claims from Difficult Airway management (1985 1999)
67% induction; 15% During surgery 12%; at extubation; 5 % during recovery

Death or Brain Damage in 58% of patients 36% 1993 -99 verses 56% in 1985 -92
( ASA Difficult Airway algorithm Published in 1993)

Airway Injury in 32% patients Median Claim : $ 424,000 ($2240 - $ 8,540,000)

Closed Claims Analysis in USA

ASA Guide lines for Management of Difficult Airway (DA)

History : Medical, surgical, anesthetic factors Physical examination : To detect physical characteristics that may indicate DA Additional evaluation : when indicated Basic Preparation: one portable storage unit that contains specialized equipment for DA
Additional trained person

Strategies for intubation: preplanned strategies

anticipated surgery, condition of patient, skills and preferences of anesthesiologist

ASA Guide lines for Management of Difficult Airway

Strategies for Extubation of DA
Awake vs deep General clinical factors Plan if patient cannot maintain adequate ventialtion after extubation Consideration of short term use of device : expedited REINTUBATION

Follow-up Care : Document presence and nature of DA

Difficulties with ventilation, LMA, tracheal intubation Techniques used : beneficial or detrimental

Awake tracheal Intubation

Natural airway ( no bridges burned) Better musle tone ( tongue, epiglottis, larynx post pharangeal muscles Larynx moves to anterior position with muscle relaxation Conventional intubation more difficult

ASA DIFFICULT AIRWAY ALGORITHM

RECOGNIZED (1) UNRECOGNIZED (2) GENERAL ANESTHESIA
PARALYSIS

AWAKE
INTUBATION

(3) CVCI RESCUE

OPTIONS

CONFIRM (4)

DIFFICULT AIRWAY ALGORITHM

RECOGNIZED

(1)

UNRECOGNIZED

AWAKE INTUBATION

PREOPERATIVE AIRWAY EVALUATION (11 STEPS)

GENERAL ANESTHESIA PARALYSIS

1-4 = FOCUS EYES ON TEETH

5-6 = FOCUS EYES INSIDE THE MOUTH ON THE PHARYNX 7,8 = MANDIBULAR SPACE EXAM 9-11 = NECK EXAM

PREOPERATIVE AIRWAY EXAMINATION

5. OROPHARYNGEAL CLASSIFICATION MALLAMPATI GRADES

6. R/O NARROW HIGH ARCHED PALATE

7. MANDIBULAR SPACE LENGTH = TMD = INDEX OF A OR P OF LARYNX

3FB OR 6 CM

Maalampati grade & Thyromental distance can predict Difficult intubation in 95% of patients.

8. MANDIBULAR SPACE COMPLIANCE 9. LENGTH OF NECK

10. THICKNESS OF NECK 11. RANGE OF MOTION OF HEAD AND NECK

RECOGNIZED

DIFFICULT AIRWAY UNRECOGNIZED

PROPER PREPARATION

MASK VENT NONPROBLEMATIC

GENERAL
ANESTHESIA PARALYSIS

AWAKE INTUBATION CHOICES SURGICAL AIRWAY

FAIL REGIONAL ANESTHESIA CONFIRM

SUCCEED

CANCEL CASE, REGROUP

Cormack-Lehane Grading of Glottic exposure on Direct laryngoscopy

Grade 1: Most of the glottis visible

Easy Grade 2: Only the Post part of the glottis visible

Grade 3: No part of the glottis visible

Grade 4: Not even epiglottis sees Difficult

Mask Ventilation

DEFINITION OF OPTIMAL MASK VENTILATION

1. BILATERAL JAW THRUST AND MASK SEAL: REQUIRES 2 PERSONS 2. BIG OROPHARYNGEAL AIRWAY 3. CONSIDER BILATERAL BIG NASOPHARYNGEAL AIRWAY (BUT VASOCONSTRICT FIRST)

MASK VENTILATION YES (NONEMERGENCY PATHWAY) NO (EMERGENCY PATHWAY)

RESCUE OPTIONS SURGICAL AIRWAY

INTUBATION CHOICES
FAIL AWAKEN ANESTHESIA WITH MASK VENTILATION

DIFFICULT AIRWAY
RECOGNIZED PRE-O2 AWAKE INTUBATION UNRECOGNIZED

GENERAL ANESTHESIA PARALYSIS

MASK VENTILATION

YES (NONEMERGENCY PATHWAY) FAIL

INTUBATION CHOICES

NO (EMERGENCY PATHWAY) RESCUE OPTIONS

DEFINITION OF OPTIMAL L-SCOPE INTUBATION ATTEMPT

1. REASONABLY EXPERIENCED ENDOSCOPIST 2. NO SIGNIFICANT MUSCLE TONE 3. OPTIMAL SNIFF POSITION 4. OPTIMAL EXTERNAL LARYNGEAL PRESSURE 5. CHANGE LENGTH OF BLADE X1 6. CHANGE TYPE OF BLADE X1
March 27, 2012

DIFFICULT AIRWAY
RECOGNIZED PRE-O2 AWAKE INTUBATION UNRECOGNIZED

GENERAL ANESTHESIA PARALYSIS

MASK VENTILATION

YES (NONEMERGENCY PATHWAY) INTUBATION FAIL CHOICES (CONTINUOUS VENTILATION

FIBEROPTIC TECHNIQUES)

NO (EMERGENCY PATHWAY) RESCUE OPTIONS

CONTINUOUS VENTILATION FIBEROPTIC TECHNIQUE

ANESTHESIA MASK WITH SELF-SEALING DIAPHRAGM FOR FOB PLUS AIRWAY INTUBATOR

FOB TO ANES. CIRCUIT BRONCH ELBOW NASEL RAE LMA BOWL OF LMA FOB THROUGH VOCAL CORDS

CONTINUOUS VENTILATION FIBEROPTIC TECHNIQUE

LMA, #
5

N-ETT mm ID
7.0

33, 4

6.0

PRESENT ASA DA-A

MASK VENTILATION

NO [EMERGENCY PATHWAY] RESCUE OPTIONS CONSIDER/ ATTEMPT LMA FIRST

YES [NONEMERGENCY
PATHWAY]

YES

AWAKEN INTUBATION CHOICES COMBITUBE TTJV

NO
SURGICAL AIRWAY

CVCI OPTIONS: CHOOSING BETWEEN THE SUPRAGLOTTIC MECHANISMS (LMA, CT) AND SUBGLOTTIC MECHANISMS (TTJV, SURG AIRWAY)
CAUSE OF CVCI GIVEN ANATOMY NO PATHOLOGY PERIGLOTTIC PATHOLOGY VENTILATORY MECHANISM SPECIFIC CHOICE

SUPRAGLOTTIC
SUBGLOTTIC

LMA, COMBITUBE
TTJV, SURGICAL AIRWAY

LMA in ASA algorithm

Supra laryngeal options

LMA

COMBITUBE

COMBITUBE
Two lumen
Et tube Esophageal Obturator airway Proximal balloon ( 100cc) at root of tongue and Soft palate Distal 10 ml balloon seals esophagus ( 99%) or trachea

AWAKE INTUBATION
Explanation : Patient understands safety Dessication : Dry the airway Dilatation : Prepare the nose Topicalization: Obtund reflexes Sedation: Maintain Patent airway control Procastination: A I cannot be rushed

Infra Glottic choices

Trans tracheal Jet ventilation : Large bore IV catheter CT membrane Needs pressure regulator ( set at 35 PSI) Surgical airway :
Cricothryrotomy ( Cook) kit Insertion of small cuffed styletted tube (through surgical incision of CT membrane

Left, A and

SIGNS OF TRACHEAL INTUBATION

I. FAILSAFE = FOB SEE TBT CARTILAGENOUS RINGS

SEE ETT BETWEEN CORDS

II.

ALMOST FAILSAFE = PETCO2 AND EDD

II.

EVERYTHING ELSE = NOT FAILSAFE AND CAN FOOL YOU

March 27, 2012

GLIDESCOPE in Difficult Airway Management

Retrospective study of 71 570 intubations at 2 major Medical centers (142 Anesthesiologists at Univ of Michigan, Ann Arbor and Univ of Oregon, Portland)

2004 GVL intubations: 97% success rate 1712 of 1755 Primary intubations 98% 224 of 239 Rescue failed direct laryngoscopy 94% Predicted Difficult Airway 96 % Patients with neck pathology, (previous surgery, radiation) Short TM distance ( <6cms), Limited cervical motion Associated with increased risk of failure BMI, Mallampati score, mouth opening are not associated with GVL failure 0.3% complication ( dental, pharyngeal, Laryngeal & tracheal injury)

Modified algorithm for Difficult Airway using modern optical devices

March 27, 2012

Jean Verdier hospital, Paris, France

Oxygenation, Not Intubation, Does Matter

Maintenance of Oxygenation or Rapid recovery from Hypoxemia is our final goal of airway management during Induction of anesthesia and Resuscitation. Difficult or Impossible FMV is more critical to be avoided in anesthetized patients than TI failure.

March 27, 2012

LMA Ctrach

Current Concepts of Management of Difficult Airway in 2011

I. Alternative Airway Devices

A) Endotracheal Tube Guides :
1. Portex Endotracheal Tube Introducer (Gum Elastic Bougie) 15 Fr. 60 cm length

2. 3. 4. 5.

Frova, Aintree Intubating Introducers Arndt Airway, Cook Airway exchange catheter (100 Cm long) Radlyn Stylet R-100, Gliderite Auto Stylet, Optishape Stylet ET view Tracheoscopic Ventialtion Tube (TVT)

B) Lighted Stylets : C) Rigid Laryngoscopes: Glidescope, Pentax AWS, Rusch Truview, Truview
EVO

D) Indirect Rigid Fiberoptic Laryngoscope: Airtraq ; Bullard elite

Laryngoscope

E) Supraglottic Airway Devices : LMA. Esophageal Tracheal Combitube

Easy tube, Laryngeal Tube, Cobra PLA, I gel, Air- Q Laryngeal, Mask,

II. Special Airway Techniques:

A. Flexible Fiberoptic Intubation B. Retrograde Intubation C.Transtracheal Jet Ventialtion D. Cricothyrotomy
Needle Cricothyrotomy Jet Ventilation Percutaneous Cricothyrotomy Seldinger Technique Surgical Cricothyrotomy

E.Tracheostomy :
Percutaneous Dilational Tracheostomy Translaryngeal Tracheostomy

THINK GLOBALLY ACT LOCALLY

Focus on GLOBAL goal of improving patients long term out come, with specifics of LOCAL Facility. All hospitals should develop LOCAL ALGORITHM for use by specific providers. ( ER, ICU, OR etc)
Identifying the problem Selecting areas of improvement Testing strategy for change Assessing data for assessing improvement Creating plans to implement improvement Continue to monitor effectiveness and make changes

THINK GLOBALLY ACT LOCALLY