management of unancipated diﬃcult tracheal intubaon in ...€¦ · l final aempt at gentle mask...

l Connue nasal oxygen using O flow at 5 L/min 2 l Maximum two more aempts preferably with a videolaryngoscope (repeat aempts only if SpO ≥95%) 2 l Gentle mask venlaon between aempts (if SpO2 95%) with two-person technique and opmal mask fit * l Opmise posion, use external laryngeal manipulaon, release cricoid pressure, use bougie / stylet if required l Consider changing device/ technique/ operator between aempts l Maintain depth of anaesthesia and opmal neuromuscular blockade Confirm tracheal intubaon using capnography Consider one of the following opons : 1. Preferably wake up the paent 2. Connue anaesthesia using the SAD only if considered safe for the paent, keeping in mind the risk of aerosolisaon 3. Tracheostomy and tracheal intubaon through SAD are not preferred Wake up the paent l Connue nasal oxygen using O flow at 5 L/min 2 l Use second generaon SAD l Maximum two aempts (only if SpO ≥ 95%) 2 l Gentle mask venlaon between aempts (if SpO2 95%) with two-hand two-person technique and opmal mask fit* l Consider changing size or type of SAD l Maintain depth of anaesthesia and opmal neuromuscular blockade l Connue nasal oxygen using O flow at 5 L/min 2 l Ensure neuromuscular blockade l Final aempt at gentle mask venlaon* using opmal technique l Connue nasal oxygen using O flow at 5 L/min and efforts 2 at rescue mask venlaon l Perform surgical cricothyroidotomy with opmal neuromuscular blockade Management of Unancipated Difficult Tracheal Intubaon in Adults during the COVID-19 Pandemic STEP 1: Laryngoscopy and tracheal intubaon Unable to intubate during first aempt at direct / videolaryngoscopy STEP 4 : Emergency cricothyroidotomy STEP 3: Rescue face mask venlaon STEP 2: Insert SAD to maintain oxygenaon Failed Intubaon Failed Venlaon through SAD Complete Venlaon Failure CALL FOR ADDITIONAL HELP If necessary, resume Gentle Mask Venlaon* (with opmal mask fit) with 100% O 2 This flow chart should be used in conjuncon with the text SAD = Supragloc airway device O= Oxygen 2 PPE =Personal Protecve Equipment SpO = Oxygen saturaon 2 Bold underlined text represents modificaons in AIDAA algorithm. *A viral filter should be present between the mask and the breathing circuit and the paent’s face should be covered with a transparent plasc sheet or a customised intubaon box during mask venlaon. Succeed Succeed C A L L F O R H E L P Post- procedure plan Succeed 1. Ensure proper disposal of single use items and disinfection of reusable items as per the institutional policy 2. Supervised doffing of PPE with proper disposal, followed by hand hygiene 3. Further airway management plan 4. Treat airway oedema if suspected 5. Monitor for complications 6. Counselling and documentation 7. Debriefing ApekshPatwa,AmitShah,RakeshGarg,JigeeshuVasishthaDivatia,PankajKundra,JesonRajanDoctor,SumalathaRadhakrishnaShetty,SyedMoied Ahmed,SabyasachiDas,SheilaNainanMyatra,AllIndiadifficultairwayassociation(AIDAA)consensusguidelinesforairwaymanagement intheoperatingroomduringtheCOVID-19pandemic.IndianJAnaesth2020;64:S107-15

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Page 1: Management of Unancipated Diﬃcult Tracheal Intubaon in ...€¦ · l Final aempt at gentle mask venlaon* using opmal technique l Connue nasal oxygen using O ﬂow a 2 t 5 L/min

l Con�nue nasal oxygen using O flow at 5 L/min2

l Maximum two more a�empts preferably with a videolaryngoscope

l (repeat a�empts only if SpO ≥95%)2

l Gentle mask ven�la�on between a�empts (if SpO2 95%) withl two-person technique and op�mal mask fit * l Op�mise posi�on, use external laryngeal manipula�on, release cricoid pressure, use bougie / stylet if requiredl Consider changing device/ technique/ operator between a�emptsl Maintain depth of anaesthesia and op�mal neuromuscular blockade

Confirm tracheal intuba�on using capnography

Consider one of the following op�ons :1. Preferably wake up the pa�ent2. Con�nue anaesthesia using the SAD only if considered safe for the pa�ent, keeping in mind the risk of aerosolisa�on 3. Tracheostomy and tracheal intuba�on through SAD are not preferred

Wake up the pa�ent

l Con�nue nasal oxygen using O flow at 5 L/min2

l Use second genera�on SAD

l Maximum two a�empts (only if SpO ≥ 95%)2

l Gentle mask ven�la�on between a�empts (if SpO2 95%) withl two-hand two-person technique and op�mal mask fit*l Consider changing size or type of SAD

l Maintain depth of anaesthesia and op�mal neuromuscular blockade

l Con�nue nasal oxygen using O flow at 5 L/min2

l Ensure neuromuscular blockadel Final a�empt at gentle mask ven�la�on* using op�mal technique

l Con�nue nasal oxygen using O flow at 5 L/min and efforts 2

at rescue mask ven�la�on l Perform surgical cricothyroidotomy with op�mall neuromuscular blockade

Management of Unan�cipated Difficult Tracheal Intuba�on in Adults during the COVID-19 Pandemic

STEP 1: Laryngoscopy and tracheal intuba�onUnable to intubate during first a�empt at direct / videolaryngoscopy

STEP 4 : Emergency cricothyroidotomy

STEP 3: Rescue face mask ven�la�on

STEP 2: Insert SAD to maintain oxygena�on

Failed Intuba�on

Failed Ven�la�on through SAD

CompleteVen�la�on

Failure

CALL FORADDITIONAL HELP

If necessary, resumeGentle Mask Ven�la�on*

(with op�mal mask fit)

with 100% O2

This flow chart should be used in conjunc�on with the text SAD = Supraglo�c airway device O= Oxygen 2

PPE =Personal Protec�ve Equipment SpO = Oxygen satura�on2

Bold underlined text represents modifica�ons in AIDAA algorithm.

*A viral filter should be present between the mask and the breathing circuit and the pa�ent’s face should be covered with a transparent plas�c sheet or a customised intuba�on box during mask ven�la�on.

Succeed

CALL

FOR

HELP

Post- procedure plan

Succeed

1. Ensure proper disposal of single use items and disinfection of reusable items as per the institutional policy2. Supervised doffing of PPE with proper disposal, followed by hand hygiene3. Further airway management plan4. Treat airway oedema if suspected5. Monitor for complications6. Counselling and documentation7. Debriefing

Apeksh�Patwa,��Amit�Shah,��Rakesh�Garg,��Jigeeshu�Vasishtha�Divatia,��Pankaj�Kundra,��Jeson�Rajan�Doctor,��Sumalatha�Radhakrishna�Shetty,�Syed�Moied�

Ahmed,�Sabyasachi�Das,�Sheila�Nainan�Myatra,��All�India�difficult�airway�association�(AIDAA)�consensus�guidelines�for�airway�management

�in�the�operating�room�during�the�COVID-19�pandemic.�Indian�J�Anaesth�2020;64:S107-15

Intubaon) *Ven’laon - WordPress.com

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