Difficult tracheal intubationDifficult tracheal intubation

Dr Tuan Pham DucDr Tuan Pham Duc

06/201006/2010

PlanPlan Preintubation checklist.Preintubation checklist. Intubation kit .Intubation kit . RSI ( Rapid sequence intubation )RSI ( Rapid sequence intubation ) Predicting difficult tracheal intubation Predicting difficult tracheal intubation Bougie ( Eschmann stylet ) .Bougie ( Eschmann stylet ) . Laryngeal mask airway-Fastrach ( Intubating LMA)Laryngeal mask airway-Fastrach ( Intubating LMA) CricothyroidotomyCricothyroidotomy Alternatives intubation techniquesAlternatives intubation techniques Confirmation of ETT placement .Confirmation of ETT placement . MiscellaneousMiscellaneous SummarySummary

Preintubation checklistPreintubation checklist

Intubation kitIntubation kit

LaryngoscopeLaryngoscope ETET StyletStylet Syringe 10mlSyringe 10ml Suction catheterSuction catheter Carbon dioxide detectorCarbon dioxide detector Oral & nasal airwaysOral & nasal airways Ambu bag & mask attached to oxygen Ambu bag & mask attached to oxygen

sourcesource

Rapid sequence intubationRapid sequence intubation

Endotracheal intubation using RSI is Endotracheal intubation using RSI is the cornerstone of emergency airway the cornerstone of emergency airway management .management .

RSI: the administration of a potent RSI: the administration of a potent induction agent followed immediatelyinduction agent followed immediatelyby a rapidly neuromuscular blocking by a rapidly neuromuscular blocking agent to induce unconsciousness & agent to induce unconsciousness & motor paralysis for tracheal motor paralysis for tracheal intubationintubation

RSIRSI

3 phases: pretreatment-induction-3 phases: pretreatment-induction-paralysis.paralysis.

Pretreatment : LOAD Lidocaine Opiod Pretreatment : LOAD Lidocaine Opiod analgesics Atropine Defasciculating analgesics Atropine Defasciculating agentsagents

Pretreatment medicationsPretreatment medications

Induction medicationsInduction medications

Paralytic medicationsParalytic medications

Predicting difficult tracheal Predicting difficult tracheal intubation intubation

LEMON ruleLEMON rule1.1. Look externallyLook externally

2.2. E Evaluate the 3-3-2 ruleE Evaluate the 3-3-2 rule

3.3. Mallampati scale Mallampati scale

4.4. Obstruction present ?Obstruction present ?

5.5. Neck mobility Neck mobility

Difficult airway assessementDifficult airway assessement

Look externally : physical features Look externally : physical features such as a small mandible , large such as a small mandible , large tongue , short bull neck & obesity , tongue , short bull neck & obesity , facial or mandibular fracture are all facial or mandibular fracture are all red flags for a difficult airwayred flags for a difficult airway

Difficult airway assessementDifficult airway assessement Mallampati classificationMallampati classification

Difficult airway assessementDifficult airway assessement

Obstruction : 3 signs of upper airway Obstruction : 3 signs of upper airway obstruction are stridor , muffled obstruction are stridor , muffled voice,difficulty swallowing secretions.voice,difficulty swallowing secretions.

Neck mobility:cervical spine Neck mobility:cervical spine immobilization in trauma , medical immobilization in trauma , medical condition such as ankylosing condition such as ankylosing spondylitis or RA.spondylitis or RA.

McCormack & Lehane gradeMcCormack & Lehane grade

Bougie ( Eschmann stylet )Bougie ( Eschmann stylet )

Bougie ( Eschmann stylet )Bougie ( Eschmann stylet )

It can be beneficial in the following It can be beneficial in the following situations :situations :

1.1. Grade 3 viewGrade 3 view

2.2. Poor grade 2 viewPoor grade 2 view

3.3. As a general intubation aidAs a general intubation aid

A bougie can be used on the 1A bougie can be used on the 1stst attempt intubation when DL has failed attempt intubation when DL has failed

to yield an adequate viewto yield an adequate view

LMALMA

A laryngeal mask airwayA laryngeal mask airway

LMALMA

Fastrach( Intubating LMA)Fastrach( Intubating LMA)

Intubating LMA sizesIntubating LMA sizes 1 (<5kg)1 (<5kg) 1,5 (10-20kg )1,5 (10-20kg ) 2,4 ( 20-50kg )2,4 ( 20-50kg ) 3,5 ( 50-70kg )3,5 ( 50-70kg ) 4,5 ( 70-100kg )4,5 ( 70-100kg )

CricothyroidotomyCricothyroidotomy

Insertion of a tracheal tube through Insertion of a tracheal tube through an incision in the cricothyroid an incision in the cricothyroid membrane .membrane .

Alternatives intubation techniquesAlternatives intubation techniques

Glottiscope ( Airtraq..)Glottiscope ( Airtraq..) Special laryngoscopesSpecial laryngoscopes Lighted stylet intubationLighted stylet intubation Fiberoptic techniques.Fiberoptic techniques. Esophageal-tracheal CombitubeEsophageal-tracheal Combitube Retrograde intubationRetrograde intubation

AirtraqAirtraq

CombitubeCombitube

Confirmation of ETT placement Confirmation of ETT placement

Chest auscultation: bilateral breath Chest auscultation: bilateral breath soundssounds

Detection of CO2 exhaled.Detection of CO2 exhaled. Chest Xray :Chest Xray :

AA- Capnography- CapnographyB-CB-C CO2 color change indicator CO2 color change indicator

MiscellanousMiscellanous

Cricoid pressure:Sellick’s maneuver Cricoid pressure:Sellick’s maneuver External Laryngeal Manipulation or External Laryngeal Manipulation or

BURP Backward Upward Right BURP Backward Upward Right Pressure maneuverPressure maneuver

1.1. ELM improved the laryngoscopic view ELM improved the laryngoscopic view by one whole grade in most pts by one whole grade in most pts initially rated 2 or 3initially rated 2 or 3

2.2. All pts presenting grade 3 view were All pts presenting grade 3 view were converted to grade 1 or 2 with ELM converted to grade 1 or 2 with ELM

SummarySummary

Always be prepared for a difficult Always be prepared for a difficult airway.airway.

No single airway assessment tool is No single airway assessment tool is sufficiently sensitive nor specific to sufficiently sensitive nor specific to reliably predict or rule out a difficult reliably predict or rule out a difficult airway.airway.

In many cases features of the In many cases features of the patient’s morphology & pathology patient’s morphology & pathology enable prediction of a difficult airwayenable prediction of a difficult airway