Airway Endoscopy and LaserAirway Endoscopy and Laser Anesthetic considerationsAnesthetic considerations

Dr. Abdul-Hamid Samarkandi, FFARCSI,KSUF

Chairman Anaesthesia Department King Saud University Hospitals

King Khalid University Hospital

Objectives:Objectives:1-1- Airway assessment and patient examination. Airway assessment and patient examination.

2-2- Mapping a plane for the perioperative Mapping a plane for the perioperative sequlae.sequlae.

3-3- Requirements for save Requirements for save endoscopy.endoscopy.

4-4- Selection for reasonable anesthetic technique. Selection for reasonable anesthetic technique.

5-5- Intraoperative challenges. Intraoperative challenges.

6- 6- Postoperative recommendations.Postoperative recommendations.

7-7- Considerations for Considerations for Laser surgery.Laser surgery.

1-1- Airway assessment and Airway assessment and patient examination.patient examination.

Must be able to assess or anticipate the degree of Must be able to assess or anticipate the degree of difficultydifficulty

Then select method most likely to succeed .Then select method most likely to succeed . Clinical Airway AssessmentClinical Airway Assessment Airway examination:Airway examination: - Indirect laryngoscope.- Indirect laryngoscope. Radiographic studiesRadiographic studies Lung reserves: flow-volume loop.Lung reserves: flow-volume loop. Reserving ICU bed for postop.respiratory careReserving ICU bed for postop.respiratory care..

* * Discusse the perioperative plan with the surgeonDiscusse the perioperative plan with the surgeon

Historical featuresHistorical features ( prior AW difficulty)( prior AW difficulty)::– Anesthesia record in old chart.Anesthesia record in old chart.– Medical alert bracelet.Medical alert bracelet.

– – Tracheostomy scar.Tracheostomy scar. Anatomical features:Anatomical features:

–– C-spine mobilityC-spine mobility

–– External dimensionsExternal dimensions ( 3-3-2 rule) ( 3-3-2 rule) * Mouth opening 3 fingers (TMJ).* Mouth opening 3 fingers (TMJ).

* Mandible large enough to accommodate * Mandible large enough to accommodate tongue. tongue.

* 3 fingers from tip of chin to hyoid.* 3 fingers from tip of chin to hyoid.

– – Length of neck/position of larynxLength of neck/position of larynx - 2 fingers - 2 fingers between top of thyroid and floor of jawbetween top of thyroid and floor of jaw

–

TeethTeeth– large or protruding incisors obstruct visionlarge or protruding incisors obstruct vision– jagged teeth can lacerate balloonjagged teeth can lacerate balloon

Oral dimensionsOral dimensions– narrow facial features and high arched narrow facial features and high arched

palates (decreased lateral space)palates (decreased lateral space)– Mallampatti classificationMallampatti classification

Mallampatti Classification Mallampatti Classification (Tongue to Pharyngeal Size) (Tongue to Pharyngeal Size)

II - soft palate, uvula, tonsillar pillars - soft palate, uvula, tonsillar pillars visiblevisible– 99 % have grade I laryngoscopic view.99 % have grade I laryngoscopic view.

IIII - soft palate, uvula visible. - soft palate, uvula visible. IIIIII - soft palate, base of uvula. - soft palate, base of uvula. IVIV - soft palate not visible - soft palate not visible

– 100% grade III or grade IV laryngoscopic 100% grade III or grade IV laryngoscopic views.views.

Mallampatti ClassificationMallampatti Classification

Predictors of DifficultPredictors of DifficultLaryngoscopyLaryngoscopy

Direct laryngoscopy intubation is difficult in 1% - Direct laryngoscopy intubation is difficult in 1% - 4% and impossible in 0.05% - 0.35% of patients 4% and impossible in 0.05% - 0.35% of patients who have seemingly normal airways.who have seemingly normal airways.

The unanticipated difficult laryngoscopy intubation The unanticipated difficult laryngoscopy intubation places patients at increased risk of complications places patients at increased risk of complications ranging from sore throat to serious airway trauma.ranging from sore throat to serious airway trauma.

Moreover, in some cases we may not be able to Moreover, in some cases we may not be able to maintain a patent airway, leading to severe maintain a patent airway, leading to severe complications such as brain damage or death.complications such as brain damage or death.

Predictors of DifficultPredictors of Difficult LaryngoscopyLaryngoscopy

Short, thick, muscular neck.Short, thick, muscular neck. Receding mandible.Receding mandible. Protruding maxillary incisorsProtruding maxillary incisors

– ““Buck teeth”Buck teeth” Poor TMJ mobility/ Poor TMJ mobility/ limited jaw openinglimited jaw opening Limited head and neck movement Limited head and neck movement

– ( including trauma )( including trauma ) High, arched palateHigh, arched palate

Predictors of DifficultPredictors of Difficult LaryngoscopyLaryngoscopy

Tumor, abscess or hematomaTumor, abscess or hematoma BurnsBurns Angioneurotic edemaAngioneurotic edema Blunt or penetrating traumaBlunt or penetrating trauma Rheumatoid arthritis, ankylosing spondylitisRheumatoid arthritis, ankylosing spondylitis Congenital syndromesCongenital syndromes Neck surgery or radiationNeck surgery or radiation

Response to Unanticipated DifficultyResponse to Unanticipated Difficulty

Difficult laryngoscopy and intubationDifficult laryngoscopy and intubation– Can’t intubate but Can’t intubate but CanCan ventilate ventilate– Can’t intubate and Can’t intubate and Can’tCan’t ventilate ventilate

Difficult Mask VentilationDifficult Mask Ventilation

Response to Unanticipated Response to Unanticipated DifficultyDifficulty

Bag the patient.Bag the patient. Maximize neck flex/ head extension.Maximize neck flex/ head extension. Move tongue out of line of site.Move tongue out of line of site. Maximize mouth opening.Maximize mouth opening. ID landmarks and adjust blade.ID landmarks and adjust blade. BURP maneuver BURP maneuver

– ((BBackwards ackwards UUpwards pwards RRightwards ightwards PPressure on ressure on Thyroid Cartilage)Thyroid Cartilage)

Increasing lifting force.Increasing lifting force. Consider Miller blade.Consider Miller blade. Bag the patient.Bag the patient.

Response to Unanticipated Response to Unanticipated DifficultyDifficulty An optimal or best attempt at difficult An optimal or best attempt at difficult

laryngoscopy should consist of :laryngoscopy should consist of :– use of optimal sniffing positionuse of optimal sniffing position– no significant muscle toneno significant muscle tone– use of optimum external laryngeal use of optimum external laryngeal

manipulation manipulation (BURP)(BURP)– one change in length of bladeone change in length of blade– one change in type of bladeone change in type of blade– a reasonably experienced laryngoscopista reasonably experienced laryngoscopist

Response to Unanticipated Response to Unanticipated DifficultyDifficulty

Remember, the first response to failure to Remember, the first response to failure to intubate should always be to intubate should always be to Bag-Mask-Bag-Mask-VentilateVentilate the patient. the patient.

The first response to failure of bag-mask-The first response to failure of bag-mask-ventilation is always ventilation is always betterbetter bag-mask-bag-mask-ventilationventilation

Algorithm for Difficulty Algorithm for Difficulty “Bagging”“Bagging”

Remove FB - Magill forceps.Remove FB - Magill forceps. Triple maneuver if c-spine clear Triple maneuver if c-spine clear

– Head tilt, jaw lift, mouth opening Head tilt, jaw lift, mouth opening Nasal (NP) or oropharyngeal (OP) airways.Nasal (NP) or oropharyngeal (OP) airways. two-person, four-hand technique.two-person, four-hand technique. Generate as much positive pressure as possible without Generate as much positive pressure as possible without

inflating the stomachinflating the stomach

Do not abandon bagging unless it is impossible with two Do not abandon bagging unless it is impossible with two people and both an OP and NP airwaypeople and both an OP and NP airway

The Failed Intubation:The Failed Intubation: Definition Definition

Three failed attempts to intubateThree failed attempts to intubate– by an experienced anesthetist.by an experienced anesthetist.

Inability to ventilate with BMVInability to ventilate with BMV

(Bag-Mask-Ventilation)(Bag-Mask-Ventilation)

Inability to oxygenateInability to oxygenate

The Failed IntubationThe Failed Intubation

If If can’t intubate but can’t intubate but cancan ventilate ventilate with with BMV have time to consider optionsBMV have time to consider options– Light guided technique (Lighted stylet)Light guided technique (Lighted stylet)– CombitubeCombitube– LMALMA– Fiberoptic techniquesFiberoptic techniques– Retrograde intubationRetrograde intubation– CricothyrotomyCricothyrotomy

Awake Oral IntubationAwake Oral Intubation

Prepare patient psychologicallyPrepare patient psychologically Pre-oxygenatePre-oxygenate Topical anesthesia if time permitsTopical anesthesia if time permits Titrated sedation - avoid obtundationTitrated sedation - avoid obtundation Reassure patient throughout procedureReassure patient throughout procedure

Difficult Airway KitDifficult Airway Kit

• Multiple blades and ETTsMultiple blades and ETTs• ETT guides (stylets, bougé, light wand)ETT guides (stylets, bougé, light wand)• Emergency nonsurgical ventilation ( LMA, Combitube, Emergency nonsurgical ventilation ( LMA, Combitube,

TTJV )TTJV )• Emergency surgical airway access ( cricothyroidotomy kit, Emergency surgical airway access ( cricothyroidotomy kit,

cricotomes ) cricotomes ) • ETT placement verificationETT placement verification• Fiberoptic and retrograde intubation Fiberoptic and retrograde intubation

The Failed IntubationThe Failed Intubation

If If can’t intubate, can’t intubate, can’tcan’t ventilate ventilate , must act , must act immediatelyimmediately– CricothyrotomyCricothyrotomy

– Urgent TracheotomyUrgent Tracheotomy

– Percutaneous Transtracheal Jet VentilationPercutaneous Transtracheal Jet Ventilation

– CombitubeCombitube

– LMALMA

The last three are temporizing measures and not The last three are temporizing measures and not definitive airway managementdefinitive airway management

Awake Oral IntubationAwake Oral Intubation

Consider for anticipated Consider for anticipated can’t intubate, can’t can’t intubate, can’t ventilateventilate situation situation

distorted upper airway anatomy distorted upper airway anatomy (i.e., penetrating neck trauma)(i.e., penetrating neck trauma)

Avoids ‘burning bridges”Avoids ‘burning bridges” maintains ventilation maintains ventilation maintains patient’s ability to protect airwaymaintains patient’s ability to protect airway

May use to take quick look to assure that you can May use to take quick look to assure that you can see enough for RSIsee enough for RSI

Difficult Airway MaximsDifficult Airway Maxims

““It is preferable to use It is preferable to use superior superior judgmentjudgment -- to avoid having to use -- to avoid having to use superior skill”.superior skill”.

Difficult airway due to Difficult airway due to upper airway pathologyupper airway pathology

Plan for tracheostomy before going to surgery Plan for tracheostomy before going to surgery (under LA) (under LA)

Awake fibroptic laryngoscope ,either nasal or Awake fibroptic laryngoscope ,either nasal or oraloral

Anesthetic management of Anesthetic management of operative endoscopiesoperative endoscopies

Preoperative preparationPreoperative preparation

Psychological preparation of patients Psychological preparation of patients and /or his relatives .and /or his relatives .

Arrangement for ICU bed.Arrangement for ICU bed. Consent for tracheostomy.Consent for tracheostomy.

Avoid sedation.Avoid sedation. Anti-sialagouge : Anti-sialagouge :

Glycopyrrolate IV or IM Glycopyrrolate IV or IM (Quaternary ammonium compound)(Quaternary ammonium compound) Atropine , ScopolamineAtropine , Scopolamine (Tertiary ammonium compounds)(Tertiary ammonium compounds) Nebulizing racemic epinephrineNebulizing racemic epinephrine Nebulizing bronchodilators.Nebulizing bronchodilators. Intravenous corticosteroid.Intravenous corticosteroid.

Intraoperative considerationsIntraoperative considerations

1- Maintaining surgical anesthesia levels:1- Maintaining surgical anesthesia levels:

- - Continuous infusion of short acting Continuous infusion of short acting anesthetics anesthetics (TIVA)(TIVA) : :

Propofol ,Alfentanil,Remifentanil.Propofol ,Alfentanil,Remifentanil.

- Supplementary volatile anesthetics .- Supplementary volatile anesthetics .

- Supplementation with:- Supplementation with:

* * -antagonists e.g.; -antagonists e.g.; Esmolol.Esmolol.

* * -agonist e.g.; -agonist e.g.; Dexemedotomidine.Dexemedotomidine.

Intraoperative considerationsIntraoperative considerations

2-The use of muscle relaxants:2-The use of muscle relaxants:

* * Continues infusion Continues infusion ofof

SUX.or Intermittent boluses of short and SUX.or Intermittent boluses of short and intermediate durations relaxants.intermediate durations relaxants.

VSVS

* * TIVA plus volatile anestheticsTIVA plus volatile anesthetics

3-Methods of ventilation3-Methods of ventilation

1- Conventional ETT anesthesia1- Conventional ETT anesthesia

using size 4.0-6.0 micro-laryngeal using size 4.0-6.0 micro-laryngeal tube.tube.

2- Insufflation's ventilation2- Insufflation's ventilation with high flows of oxygen through a small with high flows of oxygen through a small

catheter placed in the trachea. catheter placed in the trachea. better with spontaneously breathing better with spontaneously breathing

patients.patients.

3- Intermittent apnea technique :3- Intermittent apnea technique :

Periods of controlled ventilation via face mask or Periods of controlled ventilation via face mask or ETT alternated with periods of apnea.ETT alternated with periods of apnea.

4- Manual Jet Ventilation :4- Manual Jet Ventilation : The jet injector is connected to a The jet injector is connected to a high pressure source high pressure source

of oxygenof oxygen and to the side port of the laryngoscope. and to the side port of the laryngoscope. It ventilate the lungs during inspiration and allow It ventilate the lungs during inspiration and allow

period for passive expiration. period for passive expiration.

5-High -Frequency Jet Ventilation:5-High -Frequency Jet Ventilation:

Utilizes a tube in the trachea to inject small volume of Utilizes a tube in the trachea to inject small volume of gas at a rate of 80-300 times/min.gas at a rate of 80-300 times/min.

Manual intermediate- frequency jet Manual intermediate- frequency jet ventilation: ventilation:

Use small bag (0.5 l) for delivering small Use small bag (0.5 l) for delivering small volume high rate , jet like ventilation (60-150).volume high rate , jet like ventilation (60-150).

Uneventful course during endoscopyUneventful course during endoscopy

Difficulty to maintain ventilations.Difficulty to maintain ventilations. - As a complications - As a complications duringduring airway surgery: airway surgery: - Laryngeal stenosis - Laryngeal stenosis (edema, bleeding)(edema, bleeding)

- Laser surgery (- Laser surgery (fire, small size ETT)fire, small size ETT)

- As a complications - As a complications afterafter airway surgery. airway surgery. - Bleeding, edema.- Bleeding, edema. - Pneumothorax.- Pneumothorax. Intractable bronchospasm.Intractable bronchospasm.

Endoscopy under local anesthesiaEndoscopy under local anesthesia

1-Rigid bronchoscope: 1-Rigid bronchoscope:

- As rigid bronchoscopy requires straight - As rigid bronchoscopy requires straight line between object and operator for line between object and operator for visualization. - It always done under visualization. - It always done under GAGA..

Endoscopy under local anesthesiaEndoscopy under local anesthesia

2- Fiberoptic Bronchoscope2- Fiberoptic Bronchoscope - It - It Does not require straight line for image Does not require straight line for image

visualization.visualization. - It could be done under - It could be done under LA:LA: I. Topical Application of LAI. Topical Application of LA II. Nerve blockII. Nerve block III. Nebulization of LAIII. Nebulization of LA

I. Topical Application of LAI. Topical Application of LA

Step 1: Step 1: Prepare the nose with vasoconstrictor Prepare the nose with vasoconstrictor and ribbon gauze soaked with LA .and ribbon gauze soaked with LA . Step 2: Step 2: Apply LA to the base of the Apply LA to the base of the

tongue, posterior pharyngeal walltongue, posterior pharyngeal wall anterior tonsillar pillars & tonsilsanterior tonsillar pillars & tonsilsStep 3: Step 3: With the help of tongue depressorWith the help of tongue depressor apply LA to side walls of pharynxapply LA to side walls of pharynx and each pyriform fossaand each pyriform fossaStep 4: Step 4: Do Laryngoscopy and apply LA to Do Laryngoscopy and apply LA to Vallecullae,epiglottis and keep soaked gauzeVallecullae,epiglottis and keep soaked gauze to each pyriform fossa for 30 seconds toto each pyriform fossa for 30 seconds to block superior laryngeal nerveblock superior laryngeal nerveStep 5: Step 5: SAYGO ( SAYGO (SSpray pray AAs s YYou ou GOGO) to lower airway) to lower airway

II. Nerve blockII. Nerve block

1- 1- Glossopharyngeal nerve blockGlossopharyngeal nerve block

Inject 2 ml of Lignocaine 2% to the Inject 2 ml of Lignocaine 2% to the anterior pillar of the tonsil at site 1 cm anterior pillar of the tonsil at site 1 cm above the lower pole of the tonsil at the above the lower pole of the tonsil at the depth of 8mm (on each side)depth of 8mm (on each side)

II. Nerve blockII. Nerve block

2-2- Superior Laryngeal Nerve block Superior Laryngeal Nerve block

Infiltrate 2ml of Lignocaine 2% into theInfiltrate 2ml of Lignocaine 2% into the

thyro-hyoid membrane at site in between thyro-hyoid membrane at site in between the greater cornu of hyoid bone and the greater cornu of hyoid bone and superior cornu of thyroid cartilage. superior cornu of thyroid cartilage.

II. Nerve blockII. Nerve block

33- Transtracheal block :- Transtracheal block :

(Recurrent laryngeal nerve block)(Recurrent laryngeal nerve block)

Insert 22 gauge canula into trachea Insert 22 gauge canula into trachea through cricothyroid membrane or in through cricothyroid membrane or in between tracheal rings, remove the trocar, between tracheal rings, remove the trocar, aspirate air for .Forcefully Inject 4 ml of aspirate air for .Forcefully Inject 4 ml of Lignocaine 2% at the end of inspiration.Lignocaine 2% at the end of inspiration.

Post-endoscopy carePost-endoscopy care

OxygenOxygen by face-mask. by face-mask. Close monitoring for homodynamic and Close monitoring for homodynamic and

respiratory parameters (PACU) before shifting.respiratory parameters (PACU) before shifting. NPO for 4 - 6 hrs.NPO for 4 - 6 hrs. Good hydration ( IV fluids).Good hydration ( IV fluids). Racemic epinephrineRacemic epinephrine or normal saline or normal saline

Nebulization.Nebulization. Post bronchoscopy X-Ray chest.Post bronchoscopy X-Ray chest. Non-narcotics pain killers.Non-narcotics pain killers.

Lidocaine added to a tracheostomy tube cuff Lidocaine added to a tracheostomy tube cuff

reduces tube discomfortreduces tube discomfort

Tracheostomy tube cuffs were inflated with 5 ml Tracheostomy tube cuffs were inflated with 5 ml lidocaine 4% solution and air at 20 cmH2O .lidocaine 4% solution and air at 20 cmH2O .

Lidocaine diffusion across the tracheostomy tube Lidocaine diffusion across the tracheostomy tube cuff reduces tube discomfort e.g.: patients cuff reduces tube discomfort e.g.: patients undergoing oral cancer surgeryundergoing oral cancer surgery

Laser surgery and precautionsLaser surgery and precautions

Characteristics:Characteristics: - Monochromatic.- Monochromatic.

- Coherent.- Coherent.

- Collimated.- Collimated.

Advantages:Advantages: - Excellent hemostasis. - Excellent hemostasis.

- Minimal edema and pain.- Minimal edema and pain.

Laser Laser

HazardsHazards::

It depends on the medium in which laser It depends on the medium in which laser beam is generated ( wavelength).beam is generated ( wavelength).

CO2 LaserCO2 Laser (10.600 nm (10.600 nm ).is more ).is more localised,less penetratedlocalised,less penetrated

YAG LaserYAG Laser (1.060 nm (1.060 nm ).less absorbed ).less absorbed by water ,deep penetrationby water ,deep penetration

LaserLaserA. Anesthetic precautions:A. Anesthetic precautions: Suction of Laser fumes.Suction of Laser fumes. Eye protectionEye protection for all members inside the for all members inside the

theatre including the patient's eye.theatre including the patient's eye. Avoidance of ETT fire:Avoidance of ETT fire:

- Use of inflammable ETT .- Use of inflammable ETT .

e.g.; Metal, red rubber, silicon rubbere.g.; Metal, red rubber, silicon rubber

- Use intermittent apnea technique or - Use intermittent apnea technique or jet ventilation. jet ventilation.

LaserLaser

4-Use 4-Use low inspired O2low inspired O2 concentration. concentration.

5-Replace N2O by air or Helium.5-Replace N2O by air or Helium.

6-Inflate ETT cuff with mixture of lidocaine 6-Inflate ETT cuff with mixture of lidocaine and saline( 1:2).and saline( 1:2).

LaserLaser

B-Surgical precautions:B-Surgical precautions:

1- Limit the duration and intensity of the 1- Limit the duration and intensity of the Laser beam as possible.Laser beam as possible.

2-Saline soaked pledgets to be placed in the 2-Saline soaked pledgets to be placed in the airway to limit risk of ignition.airway to limit risk of ignition.

3-A 60 ml syringe filled with water to be 3-A 60 ml syringe filled with water to be standby for fire control.standby for fire control.

Airway-fire protocolAirway-fire protocol

1- Stop ventilation, Remove ETT, Turn off O2, 1- Stop ventilation, Remove ETT, Turn off O2, and and disconnect the circuitdisconnect the circuit from the machine. from the machine.

2-Submerge the ETT in water.2-Submerge the ETT in water.

3-Ventilate with Ambu bag and reintubate with 3-Ventilate with Ambu bag and reintubate with regular ETT.regular ETT.

4-Assess the airway damage (bronchoscope, 4-Assess the airway damage (bronchoscope, ABGs).ABGs).

5- Consider steroids and bronchial lavage.5- Consider steroids and bronchial lavage.

Thank You