Techniques for the Difficult Airway

Difficult AirwayI

Alexander S. Nivena and Kevin C. Doerschugb

Copyright . 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

BAGIAN ILMU ANESTESI, PERAWATAN INTENSIF, DAN MANAJEMEN NYERI

FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN

2014

Department of Medicine, Madigan Healthcare System and Uniformed Services

Department of Internal Medicine, University of Iowa Carver College of Medicine

Techniques for the

Current opinion in critical care (Impact Factor: 2.67). 12/2012;

Oleh :

Faradhillah A Suryadi c11108340

Pembimbing :

dr. Maya P Suyata

Supervisor

dr. Fransiscus J.Manibuy, Sp.An-KIC

Introduction

Management of the difficult airway is associated with

significant morbidity and mortality in critically ill

patients.

An increasing array of advanced airway tools are

available, but appropriate selection and application

in the ICU remains poorly defined.

Difficult airway incidence during emergent intubation

is 10%, but complications of ICU airway

management remain common

the importance of interdisciplinary critical care team

preparation, training, and teamwork, and the

application of various advanced airway adjunct to

maximize intubation success and minimize com

plications in this environment

The Difficult Airway

ASA : difficult airway as the existence of clinical

factors that complicate ventilation by facemask or

intubation by experienced and skilled clinicians [5]

Jaber et al. [4] : complications in 50% of 253 ICU

intubations, 28% including severe complications

(serious hypoxemia, hemodynamic instability,

cardiac arrest or death)

Martin et al. [6] : Although 44% of these

complications occurred in the ICU, the proportional

rate of complications was significantly less than that

associated with intubations performed on a ward

(P<0.001).4. Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation

in the intensive care unit: a prospective, multiple-center study. Crit Care Med 2006; 34:2355–2361.

5. American Society of Anesthesiologists. Practice guidelines for management of the difficult airway: an updated report by the

American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98:1269–1277.

6. Martin LD,Mhyre JM, Shanks AM, et al. 3,423 Emergency tracheal intuba at a University Hospital. Airway outcomes and

complications. Anesthesio 2011; 114:42–48.

Anatomy

Anatomy

Difficult Airway Management

Prediction Preparation Practice

Common risk factors associated with

a difficult airway

History Previous noted difficulties Large Tongue

Male Receding Jaw

Age 40–59 High Arched Palate

Diabetes Prominent uppers

incisors

Acromegaly Short thick neck

Rheumatoid arthritis Fixed or ‘high’ larynx

Obstructive sleep apnea Mouth opening <4 cm

Head and neck surgery, radiation Mallampati class 3 or 4

Physical exam Obesity

Upper airway trauma, burn, or swelling Reduced head/neck

mobility

Prediction

MALLAMPATI CLASSIFICATION

Class I: Soft and hard palate, tonsillar pillars, and uvula are well seen.

Class II: Tonsillar pillars and tip of the uvula are hidden.

Class III: Only soft and hard palates are visible.

Class IV: Only the hard palate is visible

Evaluating DMV

• Mask SealM

• Obesity/ ObstructionO

• No teethN

A

• StiffnessS

• Age

Evaluating DMV

• Over weight (body mass index > 26 kg/m2O

• BeardB

• Elderly (> 55 y.o)E

S

• EdentulousE

Snoring

a snoring (OBESE) Santa

Evaluating Difficult Intubation

LEMON or MELON scale

LM MAP

4 D

Wilson Risk Scale

Magboul 4M

LEMON Scale

Grading the Airway (Cormack-Lehane)

Grade I - Full view of the glottic opening

Grade II - Posterior portion of glottic opening visible

Grade III - Only tip of epiglottis is visible

Grade IV - Only soft palate is visible

Evaluating Difficult Intubation

• Look for external face deformitiesL

• MallampatiM

• Measure 3-3-2-1 fingersM

A

• Pathological obstructive conditionsP

Atlanto-occipital extension

4D

Dentition

Distortion

Disproportion

Dysmobility

4D

Wilson Risk Score

0 1 2

Weight <90 kg 90 – 110

kg

>110 kg

Head and

neck

movement

>90o 90o <90o

Jaw

movement

IG >5 cm

SL >0

IG <5 cm

SL = 0

IG <5 cm

SL < 0

Receding

mandible

Normal Moderate severe

Buck teeth Normal Moderate severe

4 M

M allampati

M easurement

M ovement

M alformation of STOPSkull,Teeth,Obstruction,Pathology

(kraniofacial abnormal & Syndromes: Treacher Collins, Goldenhar’s, Pierre

Robin, Waardenburg syndromes)

Preparation

Decide whether the basic problem is :

- Difficult ventilation

- Difficult intubation

- Uncooperative patient

Try more active to manage difficult airway

Consider the purpose of the management

- awake intubation vs intubation after induction

- Invasive or non-invasive intubation approach

- Decide the main strategy and always think about plan B

Practice

Stylets, Intubasi Guides and Bougies

Practice

Airway Exchange Catheter

Practice

Specialized Forceps

Practice

Direct Laryngoscopy

Practice

Laryngeal Mask Airway

Practice

Intubating Laryngeal Mask Airway

Practice

Video Laryngoscopy

Practice

Video Laryngoscopy

Practice

Advanced management in difficult airway

Retrograde intubation

Transtracheal Jet Ventilation

Cricothyroidotomy

Thoracostomy

Difficult airway management in the ICU

The Royal College of Anesthetists fourth National

Audit Project (NAP4) [7] : 20% airway incidents

occurred in the ICU, and 61% these episodes

resulted in death or significant neurologic injury.

the contributing factors to ICU airway management

complications: patient, staffing, training, equipment,

and environmental considerations.

Flavin K, Hornsby J, Fawcett J, et al. Structured airway intervention improves

safety of endotracheal intubation in an intensive care unit. Br J Hosp Med

2012; 73:341–344.

Equipments in drawers :

1st : Kateter suction Yankauer; Handle Laringoskop(besar dan kecil); Bilah laringoskop (Mac 3, 4, Miller,@, 3); Plester; Klem tube; Forsep Magill.

2nd : Drugs; syringe; ctistaloid; lubricant gel

3rd : Swivel adapters; stylets; dll

4th : Laringoscope fiber optic rigid.

5th : Oxygen Mask; guide wires (0,035); endotrachealtube (2-9); Cricothyrotomi set; retrograde intubation

6th : LMA ( ukuran 1-5); Disposable ambu bag; Oralairways; nasal trumpets; oral airways for fiberopticintubation; gum elastic bougie.

Flavin K, Hornsby J, Fawcett J, et al. Structured airway intervention improves

safety of endotracheal intubation in an intensive care unit. Br J Hosp Med

2012; 73:341–344.

Difficult Airway Cart

Conclusion

A systematic approach to intubation management

that emphasizes planning, preparation, and team-

work can significantly reduce intubation

complications.

Management of Difficult airway must apply the

general principles available from current medical

evidence

American Society of Anesthesiologists. Practice guidelines for management of the difficult airway: an updated

report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.

Anesthesiology 2003; 98:1269–1277.

You

BAGIAN ILMU ANESTESI, PERAWATAN INTENSIF, DAN MANAJEMEN NYERI

FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN

2014

Thank