airway nightmare

8/2/2019 Airway Nightmare

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AIRWAY NIGHTMARE

YUSFADZRY YUSUF


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INTRODUCTION

Breathlessness, shortness of breath, or dyspnea isa difficult symptom for some patients to explainand quantify.

Tend to be subjective to some individual to furtherexplain.

It can be a natural consequence of strenuousphysical exercise.

Physiological or pathological cause in origin


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Defined as the sensation of uncomfortable breathing.

This breathing discomfort may reflect an increasedawareness of breathing or the sense that breathing isdifferent, difficult or inadequate.

Several factors may operate in an individual patientto produce breathlessness.

The clinical analysis of the breathless patientcomprises both an assessment of the severity ofbreathlessness and identification of its cause.

INTRODUCTION cont..


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Begin by assessing the patients stability.

If the patient unable to talk or complete a

full sentence without pausing for a deepbreath, move quickly to stabilize thepatient.

Return to the interview after the patient ismore comfortable.


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Common cause ofbreathlessness

MINUTES HOURS DAYS-WEEKS

Pneumothorax Asthma Pleural

effusionPulmonaryembolism

Pneumonia AECOAD

Pulmonaryoedema

Pulmonaryoedema

Pneumonia

Acute asthma Metabolicacidosis

Pulmonary TB


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Anaphylaxis 50% of patient will havedyspnea associated withanaphylaxis

Aspiration Dyspnea due to aspirationgenerally begins abruptlywithin hours of the event

Cardiac tamponade Tamponade is associatedwith dyspnea, chest pain &lightheadedness


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Acutepneumonia

Prevalence of pneumonia in healthypatient with acute cough approx- 6-7%, higher in population withcomorbid illness

Respiratorymuscleweakness

40% patient with Guillain Barre syndwill requires assisted ventilation d/tmuscle weakness

Spontaneous

pneumothorax

The lifetime risk in men is 12% for

heavy smoker &


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Chronic dyspnea

Cardiac: cardiomyopathies, MI, primarypulmonary hypertension, pericardial disease.

Pulmonary: Asthma, COPD, interstitial lung

disease, chronic pneumonia, chronic pulmonaryembolism, pulmonary neoplasm (primary/mets),pleural effusions.

Miscellaneous: Anemia, neuromuscular disorder

Psychiatric: Panic attack, anxiety disorder


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Need intubation?.....


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AIRWAY ASSESSMENT

Outlines of Presentation

Anatomy Terminology

History

Physical Examination Management of Difficult Intubation


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ANATOMY I- upperrespiratory system


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ANATOMY II- Lowerrespiratory system


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ANATOMY III- larynx


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ANATOMY IV


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TERMINOLOGY I

Difficult airway is said to occurWhen one experiences difficulty with mask

ventilation, difficulty with tracheal intubationor both

Difficult mask ventilationWhen it is not possible for the unassisted

anaesthesiologist to maintain the SpO2>90% using 100% oxygen and positivepressure mask ventilation in a patient


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TERMINOLOGY II

Difficult laryngoscopyWhen it is not possible to visualize any portion

of the vocal cords with conventionallaryngoscope

Difficult endotracheal intubation

When proper insertion of the tracheal tube

with conventional laryngoscopy requires morethan 3 attempts or more than 10 minutes


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HISTORY I

Taking an adequate history isnecessary to anticipate possible

complications.


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HISTORY II

Condition that may associated with difficultairway included

Obesity Pregnancy and labour

Increased risk of laryngeal eodema in preeclamsia

Anatomical abnormalities

Microanathia Macroglossia

Congenital syndromes (eg: Pierre-Robin, Treacher-Collin)

Burn contracture involving the head and neck


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Pierre Robin syndrome

Pierre Robin syndrome is a condition

present at birth marked by a very small

lower jaw (micrognathia).

The tongue tends to fall back and

downward (glossoptosis) and there is cleft

soft palate.


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Treacher Collins Syndrome

Treacher Collins Syndrome, alsocalled mandibulofacial dysostosis,affects the head and face.Characteristics include:

down-slanting eyes

notched lower eyelids

underdevelopment or absenceof cheekbones and the side walland floor of the eye socket

lower jaw is often small andslanting

forward fair in the sideburnarea

underdeveloped, malformedand/or prominent ears


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HISTORY III

Evidence of airway obstruction

Tumour or oedema involving upper airway

Large goitre

Acute epiglottitisMaxillofacial injury

Airways burns

Cervical spine problem

Fracture-dislocation or subluxation orcervical spine

Ankylosing spondylitis, rheumatoid arthritis


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HISTORY IV

History of upper airway compromise duringsleep

History of radiotherapy head and neckregion

History of difficult intubation duringprevious anaesthetics


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HISTORY V

Past Medical HistoryBronchiol Asthma

COPDElectrolytes imbalance

Myasthenia gravis

HPT

DM

Allergy HistoryDrugs/food


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PHYSICAL EXAMINATION I

Body weight and general status

Expect difficulty in

obese patients (body weight > 90kg or >

20% above ideal weight)Pregnant ladies particularly those in third

trimester of pregnancy


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PHYSICAL EXAMINATION II

Inspection in anterior and lateralviews

Inspect the facial features for bony or

soft tissue abnormalities:Small receding chin,

Mandibular or maxillary fractures, tumourand oedema

xam ne e nec or swe ng go re


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xam ne e nec or swe ng, go re,scarring, tracheal deviation and

position of thyroid cartilage


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Inspection in anterior and


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Inspection in anterior andlateral views

Noted the pattern of respiration forpresence of stridor, tachypnoea,

respiratory distress and paradoxicalrespiration.


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PHYSICAL EXAMINATION III

Mouth Opening

Modified Mallampati Classification

Inter-incisor gap (expect difficulty if< 3cm) Any intra oral cavity swelling:

Eg ; adenotonsillar hypertrophy.

Dentition

Protruding incisors, loose or missing teeth Orthodontic work with cap, crown or dentures

Position of lower teeth in relation to upperteeth


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PHYSICAL EXAMINATION IV

Neck Movement Neck movement-flexion,extension,rotation

Excluded cervical spondylosis- any pain in theneck, or neurological symptoms in the arm

Thyromental distance- Should be > 6.5cm. Ifless expect difficulty

Sternomental distance >12.5cm, If less,expect

difficulty


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PHYSICAL EXAMINATION V

Indirect laryngscope

Relevant in laryngael tumour or thyroidenlargement scheduled for surgery

Radiological examination Chest x-ray

Cervical x-ray

To look for fracture dislocation of cervicalspines

Modified Mallampati


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Modified MallampatiClassification

Mallampati reported a correlation between the visibility oforopharyngeal structures and the degree of difficulty ofglottic exposure on direct laryngoscope

Laryngoscopy was difficult in Class III and IV

The test is performed at the patients bedside with the patientsitting up and the observer at eye level. The patient is askedto open the mouth fully and protrude the tongue.

Visualization and identification of pharyngeal structures ismade without phonation.



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Class I: Soft palate, uvula,tonsillar pillars visibleClass II: Soft palate, uvula visible, tonsillar pillars notvisible

Class III: Only soft palate visibleClass IV: No pharyngeal structures except hard palate

visible


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Cormack and LehaneClassification

Grade I Visualization of the entire laryngeal aperture Grade II Visualization of the posterior portion of laryngeal

aperture Grade III Visualization of the tip of epiglottis Grade IV Visualization of the soft palate only

In Grade III and IV, intubation is considered to be difficult


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MANAGEMENT

MANAGEMENT OF KNOWN DIFFICULTAIRWAY

Inform senior colleague, specialistin charge and discuss optionsavailable for patient

Regional anaesthesia Local anaesthesia

GA with spontaneous respiration via facialmask or laryngeal mask airway


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MANAGEMENT

Ensure Empty Stomach anddecreased gastric acidity Implementation of fasting guidelines

Use antacids or H2 receptor antagonist

Inform surgeon about Potential airway problem

Option of tracheostomy


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MANAGEMENT

Difficult Intubation Equipment

should be checked and there arein good working order

Laryngoscopes of different


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Laryngoscopes of differenttypes and sizes

ET tubes with various types


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ET tubes with various typesand sizes

Stylet and gum elastic bougie


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Stylet and gum elastic bougie

Laryngeal mask airway (LMA) of various


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Laryngeal mask airway (LMA) of varioussizes, intubating LMA, LMA Proseal,

Trachlight,


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Ambu bag

Airway adjunct such as


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Airway adjunct such as

oesohageal-tracheal Combitube,

laryngeal tube

Fibreoptic laryngoscope and its

accesories

Invasive means of airway:cricothyrotomy or minitracheostomy


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MANAGEMENT

Preoxygenation with 100%oxygen for 3-5 minutes prior toinduction of anaesthesia

Establish monitors consisting ECG, BP,pulse oximetry, capnography,


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MANAGEMENT

Ensure that the intubating conditionare optimal

Sniffing the morning air position


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MANAGEMENT

Consider using alternativelaryngoscope blade andhandle

Macoy blade to retract the

epiglottis

Straight blade in patient withreceding chin, prominentincisors or if epiglottis is long

and floppy

Short handle in a patient withshort neck and pendulousbreast


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ThankYou..

airway nightmare

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