difficult airway toolkit

8/14/2019 Difficult Airway Toolkit

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Airway management is really easyAirway management is really easy

Airway management is really easyAirway management is really easy

except when it isntexcept when it isnt

except when it isntexcept when it isnt


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Emergency Medicine

Emergency Medicine

It can be difficult toIt can be difficult to

It can be difficult toIt can be difficult to

oxygenateoxygenate

ventilateventilate

intubateintubate

perform cricothyrotomyperform cricothyrotomy


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Emergency Medicine

Emergency Medicine

To Maximize SuccessTo Maximize Success

To Maximize SuccessTo Maximize Success

recognize and predict difficultrecognize and predict difficultairwayairway

choose appropriate techniquechoose appropriate techniqueand equipmentand equipment

possess technical skills, drugs,possess technical skills, drugs,

and devicesand devices


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Emergency MedicineEmergency Medicine

Predicting thePredicting theDifficult AirwayDifficult Airway

if you have timeif you have time

Predicting thePredicting theDifficult AirwayDifficult Airway

if you have timeif you have time


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LookLook at Anatomyat AnatomyLookLook at Anatomyat Anatomy

ObesityObesity: rapid desaturation, difficult: rapid desaturation, difficultintubation, ventilationintubation, ventilation

Facial hairFacial hair: hides small chin, can: hides small chin, canmake bagging difficult / impossiblemake bagging difficult / impossible

Large teethLarge teeth: hide airway, obscure: hide airway, obscure

tube passagetube passage Jagged teethJagged teeth: lacerate balloon: lacerate balloon


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Narrow face, high-arched palateNarrow face, high-arched palate::decreased side-to-side diameterdecreased side-to-side diameter

Large tongueLarge tongue: hides airway: hides airway

False teethFalse teeth: help bagging, remove: help bagging, removefor intubationfor intubation


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ExamineExamine AirwayAirwayExamineExamine AirwayAirway


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The 3 3 2 ruleThe 3 3 2 rule

Mouth open: 3 fingersMouth open: 3 fingers

Mentum to hyoid: 3 fingersMentum to hyoid: 3 fingers Floor of mouth to thyroidFloor of mouth to thyroid

cartilage: 2 fingerscartilage: 2 fingers


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Mouth openMouth open: 3 fingers: 3 fingers Allows insertion of tube,Allows insertion of tube,

laryngoscopelaryngoscope Mentum to hyoidMentum to hyoid: 3 fingers: 3 fingers

Predicts ability to lift tonguePredicts ability to lift tongueinto mandibleinto mandible


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Floor of mouth to thyroidFloor of mouth to thyroidcartilagecartilage: 2 fingers: 2 fingers

If high larynx, airway tuckedIf high larynx, airway tuckedunder base of tongue, hard tounder base of tongue, hard to

visualizevisualize


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MallampatiMallampati ScoreScoreMallampatiMallampati ScoreScore

With patient seated: extendWith patient seated: extendneckneck open mouthopen mouth stickstick

out tongueout tongue Visualize base of tongue,Visualize base of tongue,

faucial pillars, uvula, pharynxfaucial pillars, uvula, pharynx


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MallampatiMallampati ScoreScoreMallampatiMallampati ScoreScore

DifficultyNone None Moderate Severe


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AirwayAirway ObstructionsObstructionsAirwayAirway ObstructionsObstructions


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AirwayAirway ObstructionsObstructionsAirwayAirway ObstructionsObstructions

Angioedema?Angioedema? Hematoma?Hematoma?

Look under shirt collarLook under shirt collar

Dentures?Dentures?

Epiglottis?Epiglottis?


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NeckNeck MobilityMobilityNeckNeck MobilityMobility

Prior conditionPrior condition SurgerySurgery

RheumatoidRheumatoid

arthritisarthritis

OsteoarthritisOsteoarthritis

OthersOthers


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Cervical spine rigidity:Cervical spine rigidity:reduces ability to alignreduces ability to align

anatomic axesanatomic axes Inability to mobilize neck canInability to mobilize neck can

make intubation difficult ormake intubation difficult or

impossibleimpossible


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Moving Beyond LaryngoscopyMoving Beyond LaryngoscopyMoving Beyond LaryngoscopyMoving Beyond Laryngoscopy


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Some Equipment, Old & NewSome Equipment, Old & NewSome Equipment, Old & NewSome Equipment, Old & New


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Difficult Airway CartDifficult Airway CartDifficult Airway CartDifficult Airway Cart

Bag valve maskBag valve mask CombitubeCombitube

LMALMA

Intubation LMAIntubation LMA Fiberoptic: rigid,Fiberoptic: rigid,

flexibleflexible

LightwandLightwand BougieBougie

Transtracheal jetTranstracheal jet

RetrogradeRetrograde DigitalDigital

CricothyrotomyCricothyrotomy


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1. Bag Valve Mask1. Bag Valve Mask1. Bag Valve Mask1. Bag Valve Mask


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1. Bag Valve Mask (BVM)1. Bag Valve Mask (BVM)1. Bag Valve Mask (BVM)1. Bag Valve Mask (BVM)

Practice: skills essentialPractice: skills essential Use appropriate size oral airway orUse appropriate size oral airway or

nasal trumpetnasal trumpet

Leave denturesLeave dentures Use water-soluble lubricant to getUse water-soluble lubricant to get

good seal, especially if lots of facialgood seal, especially if lots of facialhairhair


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2. Combitube2. Combitube2. Combitube2. Combitube


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Double lumen tube functions asDouble lumen tube functions asesophageal obturator airway plusesophageal obturator airway plus

standard cuffed endotracheal tubestandard cuffed endotracheal tube

Insert blindlyInsert blindly 90% esophageal90% esophageal Inflate proximal balloon: 100 mLInflate proximal balloon: 100 mL

Inflate distal balloon: 5 15mLInflate distal balloon: 5 15mL


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Seals oropharyngeal andSeals oropharyngeal andnasopharyngeal cavitiesnasopharyngeal cavities

Ventilate through blue portVentilate through blue port Good breath sounds and no air inGood breath sounds and no air in

stomachstomach continue ventilatingcontinue ventilating

No breath sounds and air in stomachNo breath sounds and air in stomach

use white tubeuse white tube


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3. Laryngeal Mask Airway3. Laryngeal Mask Airway3. Laryngeal Mask Airway3. Laryngeal Mask Airway


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IndicationsIndicationsIndicationsIndications

Routine / emergency proceduresRoutine / emergency procedures Known / unknown difficult airwayKnown / unknown difficult airway During resuscitation in profoundlyDuring resuscitation in profoundly

unconscious patient with nounconscious patient with no

glossopharyngeal or laryngealglossopharyngeal or laryngeal

reflexes when tracheal intubationreflexes when tracheal intubation

not possiblenot possible


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ContraindicationsContraindicationsContraindicationsContraindications

InIn electiveelective patient whopatient whohas not fastedhas not fasted

may have gastric contentsmay have gastric contents

has fixedhas fixed lung compliancelung compliance

is not profoundly unconsciousis not profoundly unconscious

resists LMA airway insertionresists LMA airway insertion


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UsageUsageUsageUsage
http://www.hospitalmanagement.net/contractors/anaesthesiology/intersurgical_2/http://www.hospitalmanagement.net/contractors/anaesthesiology/intersurgical_2/http://www.hospitalmanagement.net/contractors/anaesthesiology/intersurgical_2/


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LMA Take-Home PointsLMA Take-Home PointsLMA Take-Home PointsLMA Take-Home Points

Test cuff before useTest cuff before use Dont lubricate anterior maskDont lubricate anterior mask Insert only in comatose patientInsert only in comatose patient Keep cuff inflated until patientKeep cuff inflated until patient

awakeawake

Dont throw out!! Used 40 50Dont throw out!! Used 40 50timestimes


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5. Flexible Fiberoptic Scope5. Flexible Fiberoptic Scope5. Flexible Fiberoptic Scope5. Flexible Fiberoptic Scope


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AdvantagesAdvantages Allows direct airway visualizationAllows direct airway visualization

Causes little hemodynamic stressCauses little hemodynamic stress

Nasotracheal or orotracheal routeNasotracheal or orotracheal route Can be done in all age groupsCan be done in all age groups

Requires minimal neck movementRequires minimal neck movement


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DisadvantagesDisadvantages ExpensiveExpensive

Expertise requires practiceExpertise requires practice

Delicate equipment needs carefulDelicate equipment needs carefulmaintenancemaintenance

Visual field easily impaired by bloodVisual field easily impaired by bloodand secretionsand secretions


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6. Rigid Fiberoptic Scope6. Rigid Fiberoptic Scope6. Rigid Fiberoptic Scope6. Rigid Fiberoptic Scope


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BullardBullard Wu ScopeWu Scope


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UpsherUpsher GlideScopeGlideScope


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Levitan ScopeLevitan Scope



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AdvantagesAdvantages Direct airway visualizationDirect airway visualization

Minimal neck movementMinimal neck movement

May overcome difficult viewMay overcome difficult view Useful in disrupted airwayUseful in disrupted airway

Durable, sturdy instrumentsDurable, sturdy instruments

S


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DisadvantagesDisadvantages ExpensiveExpensive


Visual field easily impaired by bloodVisual field easily impaired by bloodand secretionsand secretions

Not readily availableNot readily available

7 Li h d (T hli h )

( )


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7. Lightwand (Trachlight)7. Lightwand (Trachlight)7. Lightwand (Trachlight)7. Lightwand (Trachlight)

7 Li ht d (T hli ht)

Li h d (T hli h )


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( )7 Li ht d (T hli ht)

7 Li ht d (T hli ht)


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AdvantagesAdvantages Minimal neck movementMinimal neck movement

Useful adjunct to laryngoscopyUseful adjunct to laryngoscopy

Portable and inexpensivePortable and inexpensive Usable in bloody airwayUsable in bloody airway

Provides definitive airwayProvides definitive airway

7 Li h d (T hli h )7 Li ht d (T hli ht)

( )7 Li ht d (T hli ht)


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DisadvantagesDisadvantages Blind techniqueBlind technique

May damage airwayMay damage airway

Usually requires darkened roomUsually requires darkened room Expertise requires practiceExpertise requires practice

8 I t b ti St l t (B i )8 I t b ti St l t (B i )

8 I b i S l (B i )8 I t b ti St l t (B i )


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8. Intubating Stylet (Bougie)8. Intubating Stylet (Bougie)8. Intubating Stylet (Bougie)8. Intubating Stylet (Bougie)




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Gum elastic use as guidewireGum elastic use as guidewireAdvantagesAdvantages

Gives definitive airwayGives definitive airway

Easy to learnEasy to learn InexpensiveInexpensive

Can be used blindlyCan be used blindly




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Gum elastic use as guidewireGum elastic use as guidewireDisadvantagesDisadvantages


Not recommended in cant intubateNot recommended in cant intubate/ cant ventilate scenario/ cant ventilate scenario

9 T t h l J t V til ti9 T t h l J t V til ti



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9. Transtracheal Jet Ventilation9. Transtracheal Jet Ventilation9. Transtracheal Jet Ventilation9. Transtracheal Jet Ventilation
http://www.chestjournal.org/content/vol116/issue6/images/large/cb1092477001.jpeg


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9. Transtracheal Jet Ventilation9. Transtracheal Jet Ventilation9. Transtracheal Jet Ventilation9. Transtracheal Jet Ventilation

DisadvantagesDisadvantages Significant complications ifSignificant complications if

misplacedmisplaced

Need proper equipmentNeed proper equipment Need high-pressure oxygenNeed high-pressure oxygen

Does not protect against aspirationDoes not protect against aspiration

10 R t d I t b ti10 R t d I t b ti



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10. Retrograde Intubation10. Retrograde Intubation10. Retrograde Intubation10. Retrograde Intubation




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Puncture cricothyroid membranePuncture cricothyroid membrane Thread wire through vocal cordsThread wire through vocal cords Exit nose or mouthExit nose or mouth Guide endotracheal tube throughGuide endotracheal tube through

vocal cords over wirevocal cords over wire


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10 R t d I t b ti10 Retrograde Intubation

10 R t d I t b ti10 Retrograde Int bation


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DisadvantagesDisadvantages Takes timeTakes time Requires skillRequires skill Not recommended in cannotNot recommended in cannot

intubate / cannot ventilateintubate / cannot ventilate

11 Di it l I t b ti11 Digital Intubation



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11. Digital Intubation11. Digital Intubation11. Digital Intubation11. Digital Intubation

11 Digital Intubation11 Digital Intubation



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You need long fingersYou need long fingers Make sure patient is reallyMake sure patient is really

unconsciousunconscious

Not commonly used, but can be life-Not commonly used, but can be life-saversaver

11 Digital Intubation11 Digital Intubation

11 Digital Int bation11 Digital Intubation


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IndicationsIndications Poor lighting, difficult patientPoor lighting, difficult patient

position, disrupted airway, potentialposition, disrupted airway, potential

cervical spine injurycervical spine injury Cant see larynx due to bloodCant see larynx due to blood Equipment failureEquipment failure Intubation failureIntubation failure


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12 Cricothyrotomy12 Cricothyrotomy



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12. Cricothyrotomy12. Cricothyrotomy12. Cricothyrotomy12. Cricothyrotomy

Life-saving techniqueLife-saving technique Surgical vs. needle / Seldinger vs.Surgical vs. needle / Seldinger vs.

percutaneous kitpercutaneous kit

You must know this procedureYou must know this procedurebefore starting rapid sequencebefore starting rapid sequence




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12. Cricothyrotomy12. Cricothyrotomy12. Cricothyrotomy12. Cricothyrotomy

Final common pathways for allFinal common pathways for allcannot intubate / cannot ventilatecannot intubate / cannot ventilatescenariosscenarios

The hardest part of doing aThe hardest part of doing acricothyrotomy is picking up thecricothyrotomy is picking up the

knife. Peter Rosenknife. Peter Rosen

And finallyAnd finally

And finallyAnd finally


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And finallyAnd finallyAnd finallyAnd finally

BURP your patient grab the larynxBURP your patient grab the larynxand giveand give

BackwardBackward

UpwardUpward

RightwardRightward

PressurePressure

ConclusionsConclusions

ConclusionsConclusions


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ConclusionsConclusionsConclusionsConclusions

Recognize the difficult airwayRecognize the difficult airway How much time do you have?How much time do you have?

Who else is around?Who else is around?

What is your backup procedureWhat is your backup procedure

Know both old and new methodsKnow both old and new methods

Choose backups based on skillsChoose backups based on skills


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difficult airway toolkit

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